Download 2025 ATI COMPREHENSIVE PREDICTOR ACTUAL EXAM QUESTIONS AND ANSWERS (COMPLETE STUDY GUIDE) and more Exams Nursing in PDF only on Docsity!
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- - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow
precautions) - positioning - bed making - specimen collection - I&O - VS (stable patients: What can be delegated to Assistive personnel (AP)?
- C: A nurse on a med surge unit has recieved change of shift report and will care
for 4 patients. Which of the following patients needs will the nurse assign to an AP? A. Feeding a patient who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a patient who is learning to walk with a quad cane C. Reapplying a condom catheter for a patient who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
- B
C D: A nurse is delegating the ambulation of a patient who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The patient ambulates with his slippers on over his antiembolic stockings C. The patient uses a front wheeled walker when ambulating D. The patient had pain meds 30 minutes ago E. The patient is allergic to codeine F. the patient ate 50 % of his breakfast this morning
- D: An RN is making assignments for patient care to an LPN at the beginning of
the shift. Which of the following assignments should the LPN question? A. Assisting a patient who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a patient who was admitted on the previous shift C. providing nasopharyngeal suctioning for a patient who has pneumonia D. Replacing the cartridge and tubing on a PCA pump
- B
C E: A nurse is preparing an inservice program about delegation. Which of the follow- ing elements should she identify when presenting the 5 rights of delegation. Select all: A. Right patient B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances
- B: A nurse manager of a med surge unit is assigning care responsibilities for the
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oncoming shift. A patient is waiting transfer back to the unit from the PACU following
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action is an
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example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence
- C: Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult patient that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A patient who is terminally ill hesitates to name her spouse on her durable power of attorney form
- authoritative, democratic, and laissez faire: Most managers can be catego-
rized as
- Authoritative: makes decisions of the group
motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings
- Democratic: includes the group when decisions are made
Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collabo- ration is necessary
- Laissez faire: makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation
- **- Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization:** The nurse should consider the hierarchy of human needs when
prioritizing interventions, which are?
- Airway
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Circulation: The ABC framework identifies, in order, the three basic needs for sustaining life
- ANA codes of standards: Nurses must follow what code of standards in dele-
gating and assigning tasks
- **- caring
- autonomy
- respect
- empowerment:** What values would a nurse possess to be a patient advocate?
- Patient's religion & culture: What do the nurse need to keep in mind about
the patient when being their advocate?
- A: When should planning discharge process begin?
a. at time of admission b. 2 days after patient is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order
- A group of health care professionals from different disciplines: What is an
interdisciplinary team?
- 1 & 2 = collaboration: Fill in the blank:
- is used by interdisciplinary team to make health care decisions about
patients with multiple problems. 2. , which may take place at team meet- ings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.
- **- knowledge of nursing care & its management
- a holistic understanding of the patient, her/his healthcare needs & healthcare**
systems.: What is the nurse's contribution to an interdisciplinary team?
- 2: A four-month-old infant is admitted to the pediatric intensive care unit
with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure?
- Positive Babinski.
- High-pitched cry.
- Bulging posterior fontanelle.
- Pinpoint pupils.
- 4: A patient is receiving total parenteral nutrition (TPN). To determine the
patient's tolerance of this treatment, the nurse should assess for which of the following?
- A significant increase in pulse rate.
- A decrease in diastolic blood pressure.
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- Temperature in excess of 98.6°F (37°C).
- Urine output of at least 30 cc per hour.
- 2: The patient is exhibiting symptoms of myxedema. The
nursing assessment should reveal
- increased pulse rate.
- decreased temperature.
- fine tremors.
- increased radioactive iodine uptake level.
- 3: A nonstress test is scheduled for a patient at 34 - weeks gestation
who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the patient for the diagnostic test?
- Start an intravenous line for an oxytocin infusion.
- Obtain a signed consent prior to the procedure.
- Instruct patient to push a button when she feels fetal movement.
- Attach a spiral electrode to the fetal head.
- 4: Which of the following nursing interventions is MOST important for a
45 - year-old woman with rheumatoid arthritis?
- Provide support to flexed joints with pillows and pads.
- Position her on her abdomen several times a day.
- Massage the inflamed joints with creams and oils.
- Assist her with heat application and ROM exercises.
- 1: The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient
- with his neck in a midline position and the head of the bed elevated 30°.
- side-lying with his head extended and the bed flat.
- in high Fowler's position with his head maintained in a neutral position.
- in semi-Fowler's position with his head turned to the side.
- 2: The nurse is teaching a 40 - year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the patient to
- use a new sterile catheter each time he performs a catheterization.
- perform the Valsalva maneuver(holding breath and bearing down) before doing
the catheterization.
- perform the catheterization procedure every 8 hours.
- limit his fluid intake to reduce the number of times a catheterization is needed.
- 4: A patient is being discharged with sublingual nitroglycerin
(Nitrostat). The patient should be cautioned by the nurse to
- take the medication five minutes after the pain has started.
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important
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nursing intervention is to
- monitor vital signs, especially blood pressure, every 30 minutes.
- remain at the patient's side to provide reassurance.
- tell the patient the name of the medication and its effects.
- monitor the anticholinergic effects of the medication.
- 1: The nurse is caring for patients in the skilled nursing facility. Which of
the following patients require the nurse's IMMEDIATE attention?
- A patient admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
- A patient in pain who was receiving morphine in an acute care institution and was
transferred with a prescription for acetaminophen with codeine.
- A patient who has dysuria and foul-smelling, cloudy, dark amber urine.
- An immunosuppressed patient who has not received an influenza immunization.
- 3: The nurse is observing care given to a patient experiencing severe
to panic levels of anxiety. The nurse would intervene in which of the following situations?
- The staff maintains a calm manner when interacting with the patient.
- The staff attends to patient's physical needs as necessary.
- The staff helps the patient identify thoughts or feelings that occurred prior to
the onset of the anxiety.
- The staff assesses the patient's need for medication or seclusion if
other interventions have failed to reduce anxiety.
- 3: A 69 - year-old patient is undergoing his second exchange of
intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse?
- The patient complains of pain during the inflow of the dialysate.
- The patient complains of constipation.
- The dialysate outflow is cloudy.
- There is blood-tinged fluid around the intra-abdominal catheter.
- 1: The clinic nurse is performing diet teaching with a 67 - year-old
patient with acute gout. The nurse should teach the patient to limit his intake of
- red meat and shellfish.
- cottage cheese and ice cream.
- fruit juices and milk.
- fresh fruits and uncooked vegetables.
- 3: A patient is scheduled for a left lower lobectomy. The physician has
ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the patient displays which of the
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- Agitation and decreased level of consciousness.
- Lethargy and decreased respiratory rate.
- Restlessness and increased heart rate.
- Hostility and increased blood pressure.
- 3: A 59 - year-old woman with bipolar disorder is receiving haloperidol
(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST?
- "You are seeing things that aren't real."
- "Why don't we go make some fudge."
- "You are experiencing a side effect of Haldol."
- "I'll contact your physician to change your medication."
- 4: The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for
a patient. The nurse should advise the patient the BEST time to take this medication is
- before breakfast.
- with dinner.
- with food.
- at hs.
- 3:. If a patient develops cor pulmonale (right-sided heart failure), the
nurse would expect to observe
- increasing respiratory difficulty seen with exertion.
- cough productive of a large amount of thick, yellow mucus.
- peripheral edema and anorexia.
- twitching of extremities.
- 2: The nurse is performing triage on a group of patients in the
emergency department. Which of the following patients should the nurse see FIRST?
- A 12 - year-old oozing blood from a laceration of the left thumb due to cut on a
rusty metal can.
- A 19 - year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister
but not the place and time.
- A 49 - year-old with a compound fracture of the right leg who is complaining of
severe pain.
- A 65 - year-old with a flushed face, dry mucous membranes, and a blood sugar of
470 mg/dL.
- 2: The nurse in the outpatient clinic teaches a patient with a sprained
right ankle to walk with a cane. What behavior, if demonstrated by the patient, would indicate that teaching was effective?
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- The patient advances the cane 18 inches in front of her foot with each step.
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important for the nursing care plan to include that the patient
- eat a high-protein, low-residue diet.
- lie on her unoperated side.
- exercise her arms and legs.
- cough and deep breathe.
- 4: Which of the following is a correctly stated nursing diagnosis for a
patient with abruptio placentae?
- Infection related to obstetrical trauma.
- Potential for fetal injury related to abruptio placentae.
- Potential alteration in tissue perfusion related to depletion of fibrinogen.
- Fluid volume deficit related to bleeding.
- 1: An 8 - year-old patient is returned to the recovery room after
a bronchoscopy. The nurse should position the patient
- in semi-Fowler's position.
- prone, with the head turned to the side.
- with the head of the bed elevated 45° and the neck extended.
- supine, with the head in the midline position.
- 1: Which of the following assessment findings would indicate to the nurse
the need for more sedation in a patient who is withdrawing from alcohol dependence?
- Steadily increasing vital signs.
- Mild tremors and irritability.
- Decreased respirations and disorientation.
- Stomach distress and inability to sleep.
- 4: The home care nurse is instructing a patient recently diagnosed
with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?
- During the first two weeks of treatment, the patient should cover his mouth
and nose when he coughs or sneezes.
- It is necessary for the patient to wear a mask at all times to prevent transmission
of the disease.
- The family should support the patient to help reduce feeling of low self-esteem
and isolation.
- The patient will be required to take prescribed medication for a duration of 6 -
9 months.
- 3: The nurse's INITIAL priority when managing a physically assaultive
patient is to
- restrict the patient to the room.
- place the patient under one-to-one supervision.
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- restore the patient's self-control and prevent further loss of control.
- clear the immediate area of other patients to prevent harm.
- 1: A patient with newly diagnosed type I diabetes mellitus is being seen
by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the patient at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be
- confused with cold, clammy skin and a pulse of 110.
- lethargic with hot, dry skin and rapid, deep respirations.
- alert and cooperative with a BP of 130/80 and respirations of 12.
- short of breath, with distended neck veins and a bounding pulse of 96.
- 1: The nurse is supervising the staff providing care for an 18 - month-old
hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?
- The child is placed in a private room.
- The staff removes a toy from the child's bed and takes it to the nurse's station.
- The staff offers the child french fries and a vanilla milkshake for a midafternoon
snack.
- The staff uses standard precautions.
- 3: When using restraints for an agitated/aggressive patient, which of the
following statements should NOT influence the nurse's actions during this intervention?
- The restraints/seclusion policies set forth by the institution.
- The patient's competence.
- The patient's voluntary/involuntary status.
- The patient's nursing care plan.
- 2: The nurse is caring for an 80 - year-old patient with Parkinson's
disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this patient?
- Return the patient to usual activities of daily living.
- Maintain optimal function within the patient's limitations.
- Prepare the patient for a peaceful and dignified death.
- Arrest progression of the disease process in the patient.
- 4: A patient with a peptic ulcer had a partial gastrectomy and
vagotomy (Billroth I). In planning the discharge teaching, the patient should be cautioned by the nurse about which of the following?
- Sit up for at least 30 minutes after eating.
- Avoid fluids between meals.
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- Take the patient to the dining room with 1:1 supervision.
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- Inform the patient he may go to the dining room when he controls his behavior.
- Hold the meal until the patient is able to come out of seclusion.
- Serve the meal to the patient in the seclusion room.
- 3: A patient is given morphine 6 mg IV push for postoperative pain.
Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, patient sleeping quietly. Which of the following nursing actions is MOST appropriate?
- Allow the patient to sleep undisturbed.
- Administer oxygen via facemask or nasal prongs.
- Administer naloxone (Narcan).
- Place epinephrine 1:1,000 at the bedside.
- - severe cases of Staphylococcus aureus infections including methi-
cillin-resistant Staphylococcus aureus (MRSA): What type of infectious diseases are required to be reported to the health department?
- Patient name, drug, dose, route, frequency
read back for accuracy: What is the process of taking a telephone order from a provider?
- A
B E: A nurse is caring for a patient who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the patient in a negative pressure room b) wear gloves when assisting the patient with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene
- D: A charge nurse is discussing the responsibility of nurses carig for patients
who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the patient to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the patients room c) clean contaminated surfaces in the patients room with a phenol solution d) have family members wear a gown and gloves when visiting
- A: A nurse is caring for a patient receiving IV fluids. During a routine check,
the nurse determines that the patient has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?
