ATI RN
ATI RN Comprehensive Predictor 2023 Retake 1 Questions
Question 1 of 5
An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. The nurse should review the need for the UAP to wear a face mask while in close contact with the client because the client has influenza, which is a respiratory illness that spreads through droplets. Wearing a face mask helps prevent the transmission of the virus to others. Reminding the UAP to wear a face mask is crucial for infection control and protecting the client from further complications.
Choice B is incorrect as fitted respirator masks are not necessary for routine care of clients with influenza.
Choice C is incorrect as it does not address the immediate issue of infection control.
Choice D is incorrect as it focuses on respiratory status monitoring rather than preventing the spread of infection.
Question 2 of 5
A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?
Correct Answer: C
Rationale: The correct answer is C: The system is working properly. Tidaling in the water seal chamber is an expected finding in a chest tube with a water seal drainage system. Tidaling occurs as a result of pressure changes during inhalation and exhalation, indicating that the system is functioning as intended. This movement of fluid back and forth in the water seal chamber is a normal physiological response in the presence of a chest tube.
Incorrect answers:
A: The lung has re-expanded - Tidaling does not necessarily indicate lung re-expansion. Tidaling is a mechanical phenomenon related to the functioning of the drainage system.
B: There is a loop of tubing below the drainage system - This would be more likely to cause an issue with drainage rather than tidaling in the water seal.
D: The tubing is partially obstructed by clots - This would lead to decreased or absent drainage rather than tidaling in the water seal.
Question 3 of 5
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
Correct Answer: B
Rationale: The correct answer is B: Inform clients about the action of each medication prior to administration. This is important to ensure informed consent and promote client autonomy. By explaining the medication's purpose and potential effects, the nurse empowers the client to make informed decisions about their care. This supports the principles of patient-centered care and promotes medication adherence.
Incorrect choices:
A: Avoid preparing medications for more than two clients at one time - This is not directly related to client education about medication administration.
C: Read medication labels at least two times prior to administration - While important for accuracy, this choice does not focus on client education.
D: Complete an incident report if a client vomits after taking a medication - This is important for documentation but does not address client education about medication actions.
Question 4 of 5
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago. The client is lethargic and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?
Correct Answer: B
Rationale:
Correct
Answer: B (Administer flumazenil to the client)
Rationale: Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, such as diazepam. The client ingested a potentially lethal amount of diazepam, leading to lethargy and respiratory depression. Administering flumazenil can rapidly reverse the sedative effects and improve respiratory status, preventing further complications.
Incorrect
Choices:
A: Evaluating for further suicidal behavior is important but not the immediate priority in this situation where the client's respiratory status is compromised.
C: Monitoring the IV site for thrombophlebitis is important but does not address the client's immediate need for respiratory support.
D: Initiating seizure precautions may be needed, but the priority is to address the respiratory depression first.
E, F, G: No additional options provided.
In summary, administering flumazenil is the priority to reverse sedation
Question 5 of 5
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms like shuffling gait, which is a serious adverse effect indicating potential development of tardive dyskinesia. This should be reported promptly to prevent further complications. Weight gain (
A) and dry mouth (
B) are common side effects of haloperidol and are not typically urgent. Sedation (
D) is also common but may not require immediate attention unless severe.