ATI PN COMPREHENSIVE PREDICTOR 2020 RETAKE GUIDE test bank

ATI PN COMPREHENSIVE PREDICTOR 2020 RETAKE GUIDE test bank 1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take? ANSWER: Escort the client to a quiet area on the nursing unit. - A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands. 2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination? ANSWER: Use intermittent urinary catheterization for the client at regularintervals. - A continent urinary diversion contains valvesthat prevent urine from exiting the pouch; therefore,the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch. 3. A nurse is assisting with an education program about car restraintsafety for a group of parents. Which statement by the parent indicates an understanding of the instructions? ANSWER: “My 12YO child should place the shoulder-lap seatbelt low across his hips.” - When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash. 4. A nurse isreinforcing teaching about strategiesto promote eating with a client who has COPD. Which instructionsshould the nurse include in the teaching? ANSWER: Drink high-protein and high-calorie nutritionalsupplements. - The nurse should instruct the client to drink high-protein and high-calorie nutritionalsupplements to maintain respiratory muscle function. COPD causesrespiratory stressthat leadsto hypermetabolism and wasting of the client’s muscle mass. 5. When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE is removed first? ANSWER: Gloves - The greatest risk is contamination from pathogensthat might be present on the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated. 6. A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP? ANSWER: Generalized Petechiae - Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the neck. However, petechiae all over the newborn’s body can indicate infection or decreased platelet count and should be reported to the provider. 7. A nurse is contributing to a teaching plan for a group of male adolescents about the A/E of anabolic steroid use. Which manifestations should the nurse include? ANSWER: Reduced height potential - Use of anabolic steroidsin adolescence can lead to premature epiphyseal closure, thusreducing full height potential. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne, and edema. 8. A nurse isreinforcing teaching with an older adult client who hassevere L-sided HF. Which statementshould the nurse make? ANSWER: Rest for 15 minutes between activities. - The nurse should instruct to increase his activity gradually & to rest for a period of 15 min if he becomestired. Clients who have HF should balance activity c rest to reduce cardiac workload. 9. A nurse in a LTC facility is documenting the care of an older adult client. Which information should be included in weekly nursing care summary? ANSWER: Hydration Status - Older adult client are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client’s hydration status & include this information in the weekly nursing care summary. 10. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which information? ANSWER: Motor Response - The nurse should collect data about the client’s motorresponse& assign the response a score of 1-6, according to the Glasgow Coma Scale.