ATI Comprehensive Predictor 2024/2025
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? - ANSSublimation
Rationale: 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? - ANSInitiate fall precautions
for the client
Rationale: 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? - ANSThe client is able to accurately describe the upcoming procedure
Rationale: 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? - ANSPlaces a pillow under the
client's right arm.
Rationale: 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? - ANSIntroduce 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? - ANSContact
,Rationale: 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 - ANSMassage the uterus to expel
clots
Rationale: 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? - 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) - 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
Rationale:
-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? - ANSInvestigate environmental factors that might be
contributing to client injury during these hours.
Rationale: 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? - ANS"I will
provide you with information about medical treatment to include in your living will"
, Rationale: 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? - ANSRapid speech
Rationale: 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? - ANSThe client needs assistance when transferring from
the bed to a wheelchair.
Rationale: 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? - ANSBoggy uterus
Rationale: 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? -
ANSDevelop a safety plan with the client
Rationale: 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 IV 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. - ANSFlumazenil
Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist, 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
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? - ANSSublimation
Rationale: 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? - ANSInitiate fall precautions
for the client
Rationale: 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? - ANSThe client is able to accurately describe the upcoming procedure
Rationale: 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? - ANSPlaces a pillow under the
client's right arm.
Rationale: 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? - ANSIntroduce 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? - ANSContact
,Rationale: 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 - ANSMassage the uterus to expel
clots
Rationale: 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? - 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) - 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
Rationale:
-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? - ANSInvestigate environmental factors that might be
contributing to client injury during these hours.
Rationale: 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? - ANS"I will
provide you with information about medical treatment to include in your living will"
, Rationale: 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? - ANSRapid speech
Rationale: 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? - ANSThe client needs assistance when transferring from
the bed to a wheelchair.
Rationale: 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? - ANSBoggy uterus
Rationale: 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? -
ANSDevelop a safety plan with the client
Rationale: 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 IV 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. - ANSFlumazenil
Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should
continue to support the client's respirations with a bag valve mask.
