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ATI PN Comprehensive Predictor 2023 Quizlet
1. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.
2. A client is being taught about prescribed asthma medications. Which of the following medications should the client use for treatment of an acute asthma attack?
- A. Beclomethasone
- B. Salmeterol
- C. Albuterol
- D. Montelukast
Correct answer: C
Rationale: Albuterol is the correct choice for treating acute asthma attacks because it is a short-acting bronchodilator that provides quick relief by relaxing the muscles in the airways. Beclomethasone (choice A) and Salmeterol (choice B) are long-acting medications used for controlling and preventing asthma symptoms but are not for immediate relief during an acute attack. Montelukast (choice D) is a leukotriene receptor antagonist used for asthma maintenance therapy and not for acute asthma attacks.
3. What are the nursing interventions for a patient receiving anticoagulant therapy?
- A. Monitor INR levels and check for bleeding
- B. Administer antiplatelet therapy
- C. Check for signs of DVT and provide anticoagulation
- D. Administer aspirin and monitor for bleeding
Correct answer: A
Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.
4. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?
- A. Medication history
- B. Fluid and electrolyte imbalances
- C. Psychosocial stressors
- D. Environmental factors
Correct answer: B
Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.
5. What is an important consideration in managing a patient with heart failure?
- A. Monitor daily weight
- B. Provide oxygen therapy
- C. Encourage low-sodium diet
- D. Monitor for signs of fluid overload
Correct answer: A
Rationale: The most important consideration in managing a patient with heart failure is to monitor daily weight. This allows healthcare providers to assess fluid retention, adjust medications based on weight changes, and detect early signs of worsening heart failure. While oxygen therapy may be necessary in acute situations, it is not a routine management strategy for stable heart failure patients. Encouraging a low-sodium diet is important to manage fluid retention, but daily weight monitoring is a more direct measure of fluid status. Monitoring for signs of fluid overload is essential, but monitoring daily weight is a proactive approach to detect fluid accumulation before overt symptoms appear.
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