2023 ATI PN Comprehensive Exam with Answers (177 Solved Questions)

ATI PN COMPREHENSIVE PREDICTOR FORM A, B AND C QUESTIONS AND ANSWERS WITH RATIONALES | LATEST 2023 • A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following instructions should the nurse include? ANS: Use lower-body strength RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client toreduce stress on the back • A nurse is participating in a quality improvement study about the effectiveness of client pain management in the unit. Which of the following strategies should the nurse use to collect data? ANS: Review clients’ charts for their rating of pain before pain medication was administered and 1 hr after administration RATIONALE: The nurse should collect data from clients’ charts about pain ratings before and afterpain management interventions • A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching? ANS: “Your HIV status will be shared with members of your health care team.” RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who provides direct care for the client, just like any other diagnoses • A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client’s room? ANS: Suction catheter RATIONALE: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client’s airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway • A nurse in a provider’s office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use? ANS: Coronary artery disease RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client’s risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension • A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider? ANS: 250 mL of sanguineous drainage over the last 3 hr RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child’s chest tube is excessive and the nurse should report this finding to the provider immediately • A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes. Which of the following findings should the nurse report to the provider as an indication of hyperglycemia? ANS: Polyuria RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report this finding to the provider • A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? ANS: “I will dispose of my needles in a plastic laundry detergent container.” RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container. • A nurse is caring for a client who has Alzheimer’s disease. Which of the following actions should the nurse take? ANS: Encourage the client to reminisce about the past RATIONALE: The client who has Alzheimer’s disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicitfeelings of happiness • A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider? ANS: PR interval 0.24 seconds RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval indicatesa heart block; therefore, the nurse should report this finding provider • A nurse on a medical unit is reviewing a client’s medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form? ANS: Lumbar puncture RATIONALE: The nurse should identify that a client needs to provide consent for general treatment, as well as a separate written, informed consent for any treatment that has an elementof risk, such as a lumbar puncture • A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)? ANS: A client who has a new colostomy and requires the development of a teaching plan RATIONALE: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client’s need for a teaching plan regarding the new colostomy and request that this client is reassigned to an RN.The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established • A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to one of the following interprofessional team members? ANS: Occupational therapist RATIONALE: The nurse should identify the need for a referral to an occupational therapist to teachthe client how to use special eating utensils • A nurse is preparing to perform blood glucose monitoring for a client who has type 1diabetes Mellitus. Which of the following actions should the nurse take first? ANS: Hold the finger for testing in a dependent position RATIONALE: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen • A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include? ANS: Apply the stockings in the morning RATIONALE: The nurse should instruct the client to apply the elastic stockings in the morningand remove them at the end of the day before bedtime • A nurse in a provider’s office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (Select all that apply.) ANS: Store the child’s clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing in a hot dryer for at least 20 min. RATIONALE: Transmission of lice occurs via contact with personal items. Boiling hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hotdryer for at least 20 min is an appropriate strategy • A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement tofacilitate urinary elimination? ANS: Use intermittent urinary catheterization for the client on at regular intervals RATIONALE: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drainurine from the client’s pouch. • A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take? ANS: Tell the client they should not experience any discomfort RATIONALE: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort • A nurse is caring for a client who is crying and states that their provider informed them that they have a tumor and will need a biopsy. Which of the following responsesshould the nurse make? ANS: “What have you done to help yourself get through stressful situations before?” RATIONALE: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with a stressful situation • A nurse is caring for a newborn who is 12 hr old. The nurse should expect the newborn’s stool to have which of the following characteristics within the first 24 hourfollowing birth? ANS: Dark greenish-black and viscous RATIONALE: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood • A licensed practical nurse is assisting with the preparation of a client for insertion of a peripherally inserted central venous catheter (PICC). Which of the following actions should the nurse take? ANS: Witness the client’s signature on the informed consent form. RATIONALE: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client’s signature on the consent form after ensuring the client has anunderstanding of the procedure, including its risks and benefits • A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client’s meal tray? ANS: Spaghetti noodles with red sauce RATIONALE: The nurse should identify that spaghetti noodles with red sauce is appropriate fora client who adheres to a kosher diet. • A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which ofthe following interventions should the nurse include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RATIONALE: The nurse should maintain the flow rate of the bladder irrigation to keep the urinediluted to a reddish-pink color and the tubing free of clots and bleeding • A nurse is assisting with the care of a client who is postpartum and has a deep-vein thrombosis. The client has been receiving heparin IV infusion. Which of the followingmedications should the nurse ensure is readily available? ANS: Protamine sulfate RATIONALE: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulanteffects of heparin • A nurse is reinforcing teaching with a client about how to replace their two piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest? ANS: Hold the skin taut while removing the barrier RATIONALE: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin • A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make? ANS: “What is your current understanding about the purpose of AA?” RATIONALE: The nurse should identify the client’s understanding about thepurpose ofAA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decisionmaking process. This ensures the treatment program meets the client’s individual needs and demonstrates caring by the nurse • A nurse is performing a dressing change for a client who is 3 days postoperative. Which Of the following findings should the nurse report to the provider? ANS: Yellow-green drainage at the incision line RATIONALE: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the Provider • A nurse is providing comfort to the partner of a client who has died. Which of the following statements should the nurse make? ANS: “Journaling about your relationship might help with the grieving process.” RATIONALE: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client’s relationship with their partner • A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following characteristics should the Nurse included asplacing a vulnerable person at risk for partner violence? ANS: Recent confirmation of pregnancy RATIONALE: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attentionthe child receives • A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury. Which of the following instructions for safe lifting technique should thenurse include? ANS: “You should hold a box close to your body when lifting it up.” RATIONALE: The client should hold the box as close to their body as possible to maintain balance and prevent injury • A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include? ANS: “Apply a water-based lubricant around the nostrils to prevent irritation.”RATIONALE: The client should protect their nares with a water- based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy • A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect? ANS: The client calls their partner to ask what they should wear each day RATIONALE: Clients who have dependent personality disorder have problems making everyday decisions without input from others • A nurse is caring for a client who is scheduled for a mastectomy the following day. The client is tearful and tells the nurse that they are not ready to have this procedure done at this time. Which of the following responses should the nurse make? ANS: “Would you like for me to talk to the surgeon with you?” RATIONALE: The nurse should advocate for the client’s needs by offering to talk to the surgeon with the client. The nurse should also offer moral supportand encourage the client to express their concerns and make a more informed decision • A nurse is documenting client care in the medical record. Which of the following entries should the nurse make? ANS: “Client remains NPO until x-ray procedure is complete.” RATIONALE: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation “NPO”, which is an accepted abbreviation for “nothing by mouth.” • A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should thenurse take? ANS: Observe the client’s facial expressions during communication RATIONALE: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying • A nurse is collecting data from a client who reports recent methamphetamine use. Which Of the following manifestations should the nurse expect? ANS: Dilated pupils RATIONALE: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance • A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend to the charge nurse for discharge? ANS: A client who has pneumonia and is currently receiving oral antibiotics RATIONALE: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation • A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client? ANS: Walking outside with a staff member RATIONALE: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the oneon-one nature of the activity provides the client with a sense of security • A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first? ANS: Gloves RATIONALE: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated ofthe PPE. • A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching? ANS: Strain the urine to collect stone fragments RATIONALE: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation • A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider? ANS: Muscle pain RATIONALE: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential seriousadverse effect of atorvastatin • A nurse is caring for a client who is recovering from a motor vehicle crash. The client’s employer calls to ask if the client’s injuries will prevent them from returning towork. Which of the following responses should the nurse make? ANS: “I cannot give you this information. You will need to speak with your employee.” RATIONALE: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly • A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take? ANS: Provide the client with a handheld event marker to record fetal activityRATIONALE: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button every time they feel the fetus move throughout the test, which is then logged on the paper tracing recording the heart rate and activity of the Fetus • A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching? ANS: “I should wear a soft scarf around my neck when I am outside.” RATIONALE: A client receiving radiation therapy should cover the affectedarea with loose, soft clothing to protect the skin from sun Exposure • A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make? ANS: “Rest for 15 minutes between activities.” RATIONALE: The nurse should instruct the client to increase activity gradually and tourist for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac Workload. • A nurse is caring for a client who is scheduled to undergo a thoracentesis for a left pleural effusion. In which of the following positions should the nurse plan to place theclient during the procedure? ANS: Upright with arms resting on the overbed table RATIONALE: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improveaccess to the pleural fluid • A nurse is talking with a client who says the provider agreed to initiate a do-notresuscitate (DNR) prescription. After leaving the client’s room, which of the following actions should the nurse take first? ANS: Check for documentation that the provider spoke with the clientabout theDNR RATIONALE: The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decisionand that documentation meets legal requirements • A nurse is observing a client who is in the first stage of labor. Which of the following interventions should the nurse recommend for this client? (Select all that apply.) ANS: Squatting using an exercise ball. Counterpressure to the sacral area.Pelvic rocking. RATIONALE: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions.Counterpressure to the sacral area can help decrease pain by relieving pressure on the spinal nerves caused by the fetus’s occiput.Pelvic rocking can relieve backache during the first stage of labor. To perform this action, the client hollows their back and then arches it to relieve back pain. • A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations? ANS: A visitor who develops a bruise on their head following a syncopal episode RATIONALE: The nurse should complete an incident report for an injury involving a client orvisitor