ATI Comprehensive Practice Predictor 2019 A
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was
so angry I went to the gym and worked out." The nurse should recognize the client is
demonstrating which of the following defense mechanisms? Correct Ans:- Sublimation
(The client is exhibiting behaviors consistent with sublimation, which is displayed when a
client substitutes socially unacceptable behavior for acceptable behavior.)
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take? Correct Ans:- Initiate fall
precautions for the client
(The nurse should initiate fall precautions for a client who has a new prescription for
alprazolam because common adverse effects associated with this medication are orthostatic
hypotension, dizziness, confusion, and lethargy.)
A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the
informed consent? Correct Ans:- The client is able to accurately describe the upcoming
procedure
(The ability of the client to accurately describe the upcoming procedure indicates that the
provider adequately informed the client and that the client is able to sign the informed
consent)
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the
following actions by the AP requires the nurse to intervene? Correct Ans:- Places a pillow
under the client's right arm.
(The AP should place a pillow under the client's left arm to prevent internal rotation of the
left shoulder.)
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the
following instructions should the nurse include? Correct Ans:- Introduce new foods one at a
time over 5 to 7 days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following
precautions should the nurse implement? Correct Ans:- Contact
(The nurse should implement contact precautions for a client who has an infection spread by
direct contact, such as MRSA.)
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy
lochia. Which of the following actions should the nurse take first Correct Ans:- Massage the
uterus to expel clots
(Using the EBP approach to client care, the nurse should identify that the priority action is
massaging the client's uterus. Uterine massage will expel clots and increase uterine
firmness, resulting in decreased bleeding.)
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the
following statements should the nurse include in the teaching? Correct Ans:- "Secure the
retainer clip at the level of your baby's armpits"
,A nurse is providing discharge teaching to a client who has colorectal cancer and a new
colostomy. The client states, "I'm worried about being discharged because I live alone, and
my insurance doesn't cover ostomy supplies. "Which of the following actions should the
nurse take? (SATA) Correct Ans:- -Refer the client to a community based social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups
(A social worker is necessary to help a client with self-care, as well as assist in locating
agencies who can help the client face challenges with self-care and paying for necessary
ostomy supplies. A home health nurse can assist the client in learning to care for the
colostomy as well as provide medication management and emotional support. A client who
has cancer and a new colostomy can get help with coping from a support group and possibly
receive assistance obtaining supplies from local agencies)
A nurse manager is reviewing unit records and discovers that client falls occur most
frequently during the hours of 0530 and 0730. Which of the following actions should the
nurse take when conducting a root cause analysis? Correct Ans:- Investigate
environmental factors that might be contributing to client injury during these hours.
(When conducting a root cause analysis, the nurse should look at the factors that could
possibly lead to the clients' falls. This can include environmental factors that might be
causing the problem.)
A nurse is caring for a client who has terminal illness and requests lifesaving measures if a
cardiac arrest occurs. Which of the following statements should the nurse make? Correct
Ans:- "I will provide you with information about medical treatment to include in your living
will"
(The nurses' responsibility is to provide the client with information about specific instructions
for addressing medical treatment in a living will. The nurse should assist the client while
they are able to make decisions for themself by providing information about what end-of-life
preferences to document.)
A nurse is assessing a client who has delirium. Which of the following manifestations should
the nurse expect? Correct Ans:- Rapid speech
(Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech
patterns)
A night shift nurse is giving a change of shift report to the day shift nurse on a client who is
ready for discharge. Which of the following information is the priority for the nurse to
communicate to the oncoming nurse? Correct Ans:- The client needs assistance when
transferring from the bed to a wheelchair.
(The greatest risk to this client is injury due to a fall. Therefore, the priority information for
the nurse to communicate is that the client requires assistance during transfers.)
A nurse is assessing a client during the immediate postpartum period. Which of the following
findings requires immediate intervention by the nurse? Correct Ans:- Boggy uterus
, (When using urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse
should immediately intervene to stimulate uterine contractions and prevent blood loss. If the
uterus becomes relaxed during the postpartum period, the client will rapidly lose blood
because no permanent thrombi have formed at the placenta.)
A nurse in an emergency department is preparing to discharge a client who has experienced
intimate partner violence. Which of the following actions should the nurse take first?
Correct Ans:- Develop a safety plan with the client
(The greatest risk to this client is injury from violence. Therefore, the first action the nurse
should take is to develop a safety plan with the client.)
A client is receiving lorazepam I.V for panic attacks and develops a respiratory rate of 6/min
and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse
anticipate administering. Correct Ans:- Flumazenil
(The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist/antidote, to reverse the sedative effects of lorazepam. In addition, the
nurse should continue to support the client's respirations with a bag valve mask.)
A home health nurse is planning care for an older adult client who has impaired vision.
Which of the following interventions should the nurse include in the plan of care to prevent
injury in the home? Correct Ans:- Mark the edges of the stairs for contrast
(Marking the edges of stairs with paint or colored tape for contrast can help older adult
clients who have impaired vision prevent injury by decreasing the risk of falls.)
A nurse manager is planning to make changes to the current scheduling system on the unit.
To facilitate the staff's acceptance of this change, which of the following actions should the
nurse manager take first? Correct Ans:- Provide information about scheduling issues to the
staff.
(The first stage of the change process is the unfreezing stage, when the nurse should inform
the staff about the current staffing issues. This can increase their understanding of why
changes are necessary.)
A nurse is teaching a group of guardians about child safety measures. Which of the following
statements by guardian indicates an understanding of the teaching? Correct Ans:- "I
should have my child avoid sun exposure between 10 am and 2 pm"
(To prevent sunburns, guardians should apply sunscreen, dress their child in protective
clothing, and avoid sun exposure between 1000 and 1400.)
An RN is planning care for a group of clients and is working with a licensed practical nurse
(LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate
to the LPN? Correct Ans:- Insertion of a nasogastric tube
(The nurse should delegate the insertion of a nasogastric tube to the LPN because this task
is within the LPN's scope of practice.)
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the
nurse report to the provider? Correct Ans:- Axillary temperature 36.2 C (97.2 F)
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was
so angry I went to the gym and worked out." The nurse should recognize the client is
demonstrating which of the following defense mechanisms? Correct Ans:- Sublimation
(The client is exhibiting behaviors consistent with sublimation, which is displayed when a
client substitutes socially unacceptable behavior for acceptable behavior.)
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take? Correct Ans:- Initiate fall
precautions for the client
(The nurse should initiate fall precautions for a client who has a new prescription for
alprazolam because common adverse effects associated with this medication are orthostatic
hypotension, dizziness, confusion, and lethargy.)
A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the
informed consent? Correct Ans:- The client is able to accurately describe the upcoming
procedure
(The ability of the client to accurately describe the upcoming procedure indicates that the
provider adequately informed the client and that the client is able to sign the informed
consent)
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the
following actions by the AP requires the nurse to intervene? Correct Ans:- Places a pillow
under the client's right arm.
(The AP should place a pillow under the client's left arm to prevent internal rotation of the
left shoulder.)
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the
following instructions should the nurse include? Correct Ans:- Introduce new foods one at a
time over 5 to 7 days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following
precautions should the nurse implement? Correct Ans:- Contact
(The nurse should implement contact precautions for a client who has an infection spread by
direct contact, such as MRSA.)
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy
lochia. Which of the following actions should the nurse take first Correct Ans:- Massage the
uterus to expel clots
(Using the EBP approach to client care, the nurse should identify that the priority action is
massaging the client's uterus. Uterine massage will expel clots and increase uterine
firmness, resulting in decreased bleeding.)
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the
following statements should the nurse include in the teaching? Correct Ans:- "Secure the
retainer clip at the level of your baby's armpits"
,A nurse is providing discharge teaching to a client who has colorectal cancer and a new
colostomy. The client states, "I'm worried about being discharged because I live alone, and
my insurance doesn't cover ostomy supplies. "Which of the following actions should the
nurse take? (SATA) Correct Ans:- -Refer the client to a community based social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups
(A social worker is necessary to help a client with self-care, as well as assist in locating
agencies who can help the client face challenges with self-care and paying for necessary
ostomy supplies. A home health nurse can assist the client in learning to care for the
colostomy as well as provide medication management and emotional support. A client who
has cancer and a new colostomy can get help with coping from a support group and possibly
receive assistance obtaining supplies from local agencies)
A nurse manager is reviewing unit records and discovers that client falls occur most
frequently during the hours of 0530 and 0730. Which of the following actions should the
nurse take when conducting a root cause analysis? Correct Ans:- Investigate
environmental factors that might be contributing to client injury during these hours.
(When conducting a root cause analysis, the nurse should look at the factors that could
possibly lead to the clients' falls. This can include environmental factors that might be
causing the problem.)
A nurse is caring for a client who has terminal illness and requests lifesaving measures if a
cardiac arrest occurs. Which of the following statements should the nurse make? Correct
Ans:- "I will provide you with information about medical treatment to include in your living
will"
(The nurses' responsibility is to provide the client with information about specific instructions
for addressing medical treatment in a living will. The nurse should assist the client while
they are able to make decisions for themself by providing information about what end-of-life
preferences to document.)
A nurse is assessing a client who has delirium. Which of the following manifestations should
the nurse expect? Correct Ans:- Rapid speech
(Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech
patterns)
A night shift nurse is giving a change of shift report to the day shift nurse on a client who is
ready for discharge. Which of the following information is the priority for the nurse to
communicate to the oncoming nurse? Correct Ans:- The client needs assistance when
transferring from the bed to a wheelchair.
(The greatest risk to this client is injury due to a fall. Therefore, the priority information for
the nurse to communicate is that the client requires assistance during transfers.)
A nurse is assessing a client during the immediate postpartum period. Which of the following
findings requires immediate intervention by the nurse? Correct Ans:- Boggy uterus
, (When using urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse
should immediately intervene to stimulate uterine contractions and prevent blood loss. If the
uterus becomes relaxed during the postpartum period, the client will rapidly lose blood
because no permanent thrombi have formed at the placenta.)
A nurse in an emergency department is preparing to discharge a client who has experienced
intimate partner violence. Which of the following actions should the nurse take first?
Correct Ans:- Develop a safety plan with the client
(The greatest risk to this client is injury from violence. Therefore, the first action the nurse
should take is to develop a safety plan with the client.)
A client is receiving lorazepam I.V for panic attacks and develops a respiratory rate of 6/min
and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse
anticipate administering. Correct Ans:- Flumazenil
(The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist/antidote, to reverse the sedative effects of lorazepam. In addition, the
nurse should continue to support the client's respirations with a bag valve mask.)
A home health nurse is planning care for an older adult client who has impaired vision.
Which of the following interventions should the nurse include in the plan of care to prevent
injury in the home? Correct Ans:- Mark the edges of the stairs for contrast
(Marking the edges of stairs with paint or colored tape for contrast can help older adult
clients who have impaired vision prevent injury by decreasing the risk of falls.)
A nurse manager is planning to make changes to the current scheduling system on the unit.
To facilitate the staff's acceptance of this change, which of the following actions should the
nurse manager take first? Correct Ans:- Provide information about scheduling issues to the
staff.
(The first stage of the change process is the unfreezing stage, when the nurse should inform
the staff about the current staffing issues. This can increase their understanding of why
changes are necessary.)
A nurse is teaching a group of guardians about child safety measures. Which of the following
statements by guardian indicates an understanding of the teaching? Correct Ans:- "I
should have my child avoid sun exposure between 10 am and 2 pm"
(To prevent sunburns, guardians should apply sunscreen, dress their child in protective
clothing, and avoid sun exposure between 1000 and 1400.)
An RN is planning care for a group of clients and is working with a licensed practical nurse
(LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate
to the LPN? Correct Ans:- Insertion of a nasogastric tube
(The nurse should delegate the insertion of a nasogastric tube to the LPN because this task
is within the LPN's scope of practice.)
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the
nurse report to the provider? Correct Ans:- Axillary temperature 36.2 C (97.2 F)
