ATI RN Comprehensive Predictor
2019 Form A
1. A nurse is caring for a client who has a new prescription for enoxaparin. Which
of the following actions should the nurse take?
A. Administer the medication intramuscularly.
B. Expel the air bubble from the prefilled syringe before injection.
C. Administer the medication in the client's abdomen.
D. Massage the injection site after administration.
Answer: C. Administer the medication in the client's abdomen.
Rationale: Enoxaparin is a low-molecular-weight heparin that must be administered
subcutaneously, and the preferred site is the abdomen. It should not be given IM, air
bubbles should not be expelled to avoid medication loss, and the site should not be
massaged to prevent bruising.
2. A charge nurse is observing a newly licensed nurse perform a sterile dressing
change. Which of the following actions by the newly licensed nurse indicates a
need for intervention?
A. The nurse opens the sterile kit away from their body.
B. The nurse sets up the sterile field at waist level.
C. The nurse places the sterile dressing within the 1-inch border of the field.
D. The nurse reaches over the sterile field to obtain an item.
,Answer: D. The nurse reaches over the sterile field to obtain an item.
Rationale: Reaching over a sterile field contaminates it. The 1-inch border is considered
non-sterile. Opening the kit away from the body and maintaining the field at waist level
are appropriate sterile techniques.
3. A charge nurse is assigning client care on a medical-surgical unit. Which client
should be assigned to a newly licensed registered nurse (RN)?
A. A client with a chest tube and continuous bubbling in the water seal chamber
B. A client with new-onset atrial fibrillation receiving a heparin drip
C. A client with stable pneumonia receiving oral antibiotics
D. A client with a tracheostomy requiring suctioning every 2 hours
Answer: C. A client with stable pneumonia receiving oral antibiotics.
Rationale: Newly licensed RNs should be assigned stable clients with predictable
outcomes. Clients requiring chest tube management, IV heparin, or tracheostomy
suctioning need more experienced nursing judgment.
4. A nurse is delegating tasks to assistive personnel (AP). Which of the following
tasks is appropriate for the nurse to delegate?
A. Assessing a client's pain level
B. Obtaining vital signs on a stable postoperative client
C. Evaluating the effectiveness of a client's breathing treatment
D. Teaching a client how to use an incentive spirometer
Answer: B. Obtaining vital signs on a stable postoperative client.
Rationale: AP can perform routine tasks such as obtaining vital signs on stable clients.
, Assessment, evaluation, and teaching are within the RN's scope of practice and cannot
be delegated.
5. A nurse is caring for a client who has a pneumothorax. Which of the following
manifestations should the nurse expect?
A. Blood-tinged sputum
B. Paradoxical chest movement
C. Asymmetry of the chest
D. Bilateral crackles
Answer: C. Asymmetry of the chest.
Rationale: A pneumothorax causes air in the pleural space, leading to lung collapse on
the affected side. This results in decreased chest expansion and asymmetry. Paradoxical
chest movement is seen with flail chest, and crackles are associated with fluid in the
lungs.
6. A nurse is preparing the body of a client who has died for the family to view.
Which of the following actions should the nurse take?
A. Remove the client's identification tags
B. Place a pillow under the client's head
C. Place the client's arms across their chest
D. Remove the client's dentures
Answer: C. Place the client's arms across their chest.
Rationale: The nurse should place the client in a natural, comfortable position, typically
with arms across the chest or at the sides. Identification tags should remain in place.
Dentures are usually left in to maintain facial structure.
2019 Form A
1. A nurse is caring for a client who has a new prescription for enoxaparin. Which
of the following actions should the nurse take?
A. Administer the medication intramuscularly.
B. Expel the air bubble from the prefilled syringe before injection.
C. Administer the medication in the client's abdomen.
D. Massage the injection site after administration.
Answer: C. Administer the medication in the client's abdomen.
Rationale: Enoxaparin is a low-molecular-weight heparin that must be administered
subcutaneously, and the preferred site is the abdomen. It should not be given IM, air
bubbles should not be expelled to avoid medication loss, and the site should not be
massaged to prevent bruising.
2. A charge nurse is observing a newly licensed nurse perform a sterile dressing
change. Which of the following actions by the newly licensed nurse indicates a
need for intervention?
A. The nurse opens the sterile kit away from their body.
B. The nurse sets up the sterile field at waist level.
C. The nurse places the sterile dressing within the 1-inch border of the field.
D. The nurse reaches over the sterile field to obtain an item.
,Answer: D. The nurse reaches over the sterile field to obtain an item.
Rationale: Reaching over a sterile field contaminates it. The 1-inch border is considered
non-sterile. Opening the kit away from the body and maintaining the field at waist level
are appropriate sterile techniques.
3. A charge nurse is assigning client care on a medical-surgical unit. Which client
should be assigned to a newly licensed registered nurse (RN)?
A. A client with a chest tube and continuous bubbling in the water seal chamber
B. A client with new-onset atrial fibrillation receiving a heparin drip
C. A client with stable pneumonia receiving oral antibiotics
D. A client with a tracheostomy requiring suctioning every 2 hours
Answer: C. A client with stable pneumonia receiving oral antibiotics.
Rationale: Newly licensed RNs should be assigned stable clients with predictable
outcomes. Clients requiring chest tube management, IV heparin, or tracheostomy
suctioning need more experienced nursing judgment.
4. A nurse is delegating tasks to assistive personnel (AP). Which of the following
tasks is appropriate for the nurse to delegate?
A. Assessing a client's pain level
B. Obtaining vital signs on a stable postoperative client
C. Evaluating the effectiveness of a client's breathing treatment
D. Teaching a client how to use an incentive spirometer
Answer: B. Obtaining vital signs on a stable postoperative client.
Rationale: AP can perform routine tasks such as obtaining vital signs on stable clients.
, Assessment, evaluation, and teaching are within the RN's scope of practice and cannot
be delegated.
5. A nurse is caring for a client who has a pneumothorax. Which of the following
manifestations should the nurse expect?
A. Blood-tinged sputum
B. Paradoxical chest movement
C. Asymmetry of the chest
D. Bilateral crackles
Answer: C. Asymmetry of the chest.
Rationale: A pneumothorax causes air in the pleural space, leading to lung collapse on
the affected side. This results in decreased chest expansion and asymmetry. Paradoxical
chest movement is seen with flail chest, and crackles are associated with fluid in the
lungs.
6. A nurse is preparing the body of a client who has died for the family to view.
Which of the following actions should the nurse take?
A. Remove the client's identification tags
B. Place a pillow under the client's head
C. Place the client's arms across their chest
D. Remove the client's dentures
Answer: C. Place the client's arms across their chest.
Rationale: The nurse should place the client in a natural, comfortable position, typically
with arms across the chest or at the sides. Identification tags should remain in place.
Dentures are usually left in to maintain facial structure.
