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PN ATI Comprehensive Predictor
1. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
- A. Allow the client to sleep undisturbed
- B. Administer oxygen via facemask or nasal prongs
- C. Administer naloxone (Narcan)
- D. Place epinephrine 1:1,000 at the bedside
Correct answer: C
Rationale: The correct answer is to administer naloxone (Narcan). The client's vital signs indicate opioid-induced respiratory depression, which is a potential side effect of morphine. Naloxone is used to reverse the effects of opioids, particularly to restore normal respiratory function. Administering oxygen alone (Choice B) may not address the underlying cause of respiratory depression. Allowing the client to sleep undisturbed (Choice A) is inappropriate when signs of respiratory depression are present. Epinephrine (Choice D) is not indicated in this situation and is not used to reverse opioid effects.
2. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
- A. Serum albumin level of 3 g/dL
- B. HDL level of 90 mg/dL
- C. Norton scale score of 18
- D. Braden scale score of 20
Correct answer: A
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, which is commonly associated with pressure ulcers. This finding suggests that the client may be at risk for developing or already has a pressure ulcer due to malnutrition. High-density lipoprotein (HDL) level of 90 mg/dL (Choice B) is not directly related to pressure ulcers. The Norton scale (Choice C) is used to assess a client's risk of developing pressure ulcers, not as a finding in a client with an existing pressure ulcer. The Braden scale (Choice D) is also a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer.
3. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink liquids right up until the procedure.
- B. I will need to stop eating and drinking at least 24 hours before the procedure.
- C. I will be sedated and will not feel any pain during the procedure.
- D. I will not need to follow any specific dietary restrictions for this procedure.
Correct answer: C
Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.
4. A client has expressive aphasia following a stroke. Which of the following methods should be used when communicating with the client?
- A. Speak slowly
- B. Provide written instructions
- C. Use a picture board
- D. Write on a whiteboard
Correct answer: C
Rationale: When communicating with a client who has expressive aphasia, using a picture board is an effective method as it provides an alternative means of communication. Option A, speaking slowly, may not improve understanding for someone with expressive aphasia. Option B, providing written instructions, may also be challenging for individuals with this condition. Option D, writing on a whiteboard, may not be as helpful as using a picture board in facilitating communication for a client with expressive aphasia.
5. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?
- A. Heart rate 60/min
- B. Increased urinary output
- C. Increased respiratory rate
- D. Hypothermia
Correct answer: C
Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.
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