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Ace Your Test with ATI Predator Actual Questions and Solutions - Full Set

Free ATI Predator Questions

1. A nurse is assisting with the care of a client. Which of the following findings requires further action by the nurse? (Select all that apply.)

Exhibit 1 – Medical History: Otosclerosis with conductive hearing loss, left greater than right. Bilateral tinnitus.

Exhibit 2 – Nurses' Notes: 0730 Preoperative: Client is scheduled for a left stapedectomy. Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical. Mucous membranes show color expected for client's skin tone and moist. Speech clear. Skin warm and dry. Lungs clear bilaterally. Apical heart rate regular at 78/min.

1230 Postoperative: Pupils 3 mm, equal, and reactive to light. Smile asymmetrical. Mucous membranes pink. Speech hoarse. Client with left facial droop. Skin warm and dry. Client reports vertigo and nausea. Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min. Client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. Client states that hearing has diminished following surgery.

  • Lung assessment

  • Diminished hearing

  • Pain rating

  • Facial nerve assessment

  • Pupils

  • Vertigo

Explanation

Explanation
Correct Answers: (D) Facial nerve assessment, (E) Pupils, and (F) Vertigo
Comparing the preoperative and postoperative assessments reveals three new concerning findings that require further nursing action.
Facial nerve assessment is required because the client developed an asymmetrical smile and left facial droop postoperatively that were not present before surgery. The facial nerve (cranial nerve VII) runs in close proximity to the surgical site during a stapedectomy. New facial asymmetry and drooping indicate possible facial nerve damage, which is a serious surgical complication requiring immediate provider notification.
Pupils require further assessment because the postoperative pupil size changed from 3.5 mm preoperatively to 3 mm postoperatively. While pupils remain equal and reactive, this change in size warrants monitoring as it may reflect effects of anesthesia, medication, or neurological changes following the procedure.
Vertigo requires further action because although some degree of vertigo is expected after stapedectomy due to inner ear manipulation, it is accompanied here by nausea and represents a new postoperative symptom that must be monitored closely and reported to the provider to ensure it does not worsen or indicate a complication such as perilymph fistula.
Why Other Options do not require further action:
A. Lung assessment Bilateral breath sounds are clear and present throughout in the postoperative assessment, which is the same as the preoperative finding. There is no new respiratory concern requiring further action.
B. Diminished hearing While the client reports decreased hearing following surgery, this is an expected and anticipated finding immediately after a stapedectomy due to postoperative swelling and packing in the ear canal. It does not require further action at this time.
C. Pain rating The client rates left ear discomfort as 5 out of 10. Some degree of postoperative ear pain is expected following a stapedectomy. A pain rating of 5 should be addressed with prescribed analgesics but does not represent an urgent finding requiring further investigation beyond standard pain management.
2. A nurse is collecting data from a client who is receiving sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an adverse effect of this medication?
  • Constipation

  • Tinnitus

  • Rash

  • Hypotension

Explanation

Explanation
A rash is a known adverse effect of sulfasalazine and can indicate a hypersensitivity reaction to the medication. Sulfasalazine contains a sulfonamide component, and clients with sulfa allergies are particularly at risk for developing skin reactions ranging from mild rash to severe reactions such as Stevens-Johnson syndrome. The nurse must report this finding to the provider immediately.
Why the other options are incorrect:
A. Constipation — Sulfasalazine is used to treat ulcerative colitis, a condition characterized by diarrhea. Constipation is not a known adverse effect of sulfasalazine. Nausea, vomiting, and anorexia are more common gastrointestinal adverse effects.
B. Tinnitus — Tinnitus is associated with medications such as aspirin and aminoglycoside antibiotics, not sulfasalazine. It is not a recognized adverse effect of this medication.
D. Hypotension — Hypotension is not a known adverse effect of sulfasalazine. It is more commonly associated with antihypertensive medications or severe allergic reactions requiring separate assessment.
3. A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?
  • Change the IV solution bag.

  • Calculate IV intake.

  • Regulate the IV flow rate.

  • Report any IV infusion alarms.

Explanation

Explanation
Assistive personnel can be delegated the task of reporting IV infusion alarms to the nurse. This is within the AP's scope as it requires only observation and communication, not clinical judgment or nursing assessment. The nurse retains responsibility for assessing and responding to the alarm.
Why the other options are incorrect:
A. Change the IV solution bag — Changing IV solution bags involves clinical knowledge and verification of the correct solution, concentration, and rate. This is a nursing responsibility and cannot be delegated to an AP.
B. Calculate IV intake — Calculating IV intake requires accurate mathematical computation and clinical documentation skills that are part of the nurse's responsibility for fluid balance monitoring. This cannot be delegated to an AP.
C. Regulate the IV flow rate — Adjusting or regulating the IV flow rate requires nursing judgment and knowledge of the prescribed infusion rate and the client's clinical status. This is outside the scope of an AP and cannot be delegated.
4. A nurse is collecting data from a client who has fluid volume excess. Which of the following findings should the nurse expect?
  • Weight loss

  • Increased hematocrit

  • Crackles in the lungs

  • Weak peripheral pulses

Explanation

Explanation
Fluid volume excess, also known as hypervolemia, occurs when there is too much fluid in the intravascular space. Excess fluid accumulates in the lungs, causing pulmonary edema, which manifests as crackles (rales) heard on auscultation. This is a hallmark sign of fluid volume excess.

Why the other options are incorrect:
A. Weight loss — Fluid volume excess causes weight gain, not weight loss, due to fluid retention and accumulation in body tissues and cavities.

B. Increased hematocrit — Fluid volume excess dilutes the blood, leading to a decreased hematocrit, not an increased one. Increased hematocrit is associated with fluid volume deficit.

D. Weak peripheral pulses — Weak peripheral pulses are a sign of fluid volume deficit due to decreased circulating volume. In fluid volume excess, peripheral pulses are typically bounding and full due to increased intravascular pressure.
5. A nurse is assisting in the care of a client in the intensive care unit (ICU).

Exhibit 1 – Admission Assessment Day 1, 1000: An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside. Past Medical History: hypertension, congestive heart failure, Parkinson's disease. Allergies: penicillin (anaphylaxis). Social History: Client has visual loss but didn't bring their glasses. The client is hard of hearing. Hearing aids in place.

Exhibit 2 – Nurses' Notes Day 1, 1000: Left hip surgical wound warm, appears inflamed, and tender to touch. Thick, yellow discharge noted on dressing. Provider notified. Day 1, 1100: Nurse at bedside to check the client. Client states, "When am I going home?" The client is oriented to person and place only. Client states, "It's 1975." Client reoriented. Day 1, 1200: Nurse found the client attempting to climb out of their hospital bed. Staff assisted client back in bed. Day 1, 1230: Client starts screaming, "Can someone please call pest control and get these spiders off me and my bed! I can feel them crawling all over me!" Client oriented to person only and believes they are at home.

Exhibit 3 – Vital Signs Blood pressure 88/50 mm Hg Heart rate 105/min Respiratory rate 18/min Temperature 38.6°C (101.4°F)

Exhibit 4 – Laboratory Results Day 1, 1000: WBC count 14,000/mm³ (5,000 to 10,000/mm³)

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that the client's ______ (Target 1) and ______ (Target 2) can indicate the development of delirium.

Word Choices: past medical history, change in orientation, illusions, hallucinations

  • past medical history
  • change in orientation
  • illusions
  • hallucinations

Explanation

Explanation
The nurses' notes clearly document a progressive change in orientation — the client went from being oriented to person, place, and time at admission to only oriented to person by 1230. Additionally, the client experienced hallucinations, specifically seeing and feeling spiders that were not present. Both of these are hallmark signs of delirium, which is characterized by an acute fluctuating change in mental status, disorientation, and perceptual disturbances such as hallucinations.
Why the other options are incorrect:
Past medical history While the client has conditions such as hypertension, congestive heart failure, and Parkinson's disease that may increase the risk for delirium, the past medical history itself does not indicate the development of delirium — it is a risk factor, not a clinical indicator.
Illusions An illusion is a misinterpretation of a real external stimulus. The client's experience of seeing and feeling spiders with no real stimulus present describes hallucinations, not illusions, making this option incorrect in this context.
6. A nurse is reinforcing teaching with a client who has GERD. Which of the following instructions should the nurse include?
  • "Avoid eating snacks at bedtime."

  • "Use peppermint extract for an upset stomach."

  • "Limit foods that contain sodium."

  • "Sleep in a prone position."

Explanation

Explanation
Eating close to bedtime increases gastric acid production and promotes reflux by allowing food and acid to flow back into the esophagus when lying down. Clients with GERD should avoid eating for at least 2 to 3 hours before lying down or going to sleep to reduce symptoms.
Why the other options are incorrect:
B. "Use peppermint extract for an upset stomach." Peppermint relaxes the lower esophageal sphincter, which worsens GERD symptoms by allowing stomach acid to reflux into the esophagus more easily. Peppermint is contraindicated for clients with GERD.
C. "Limit foods that contain sodium." Sodium restriction is relevant for conditions such as hypertension and heart failure, not GERD. GERD management focuses on avoiding trigger foods such as spicy foods, fatty foods, caffeine, chocolate, and acidic foods.
D. "Sleep in a prone position." Sleeping in a prone (face-down) position does not help GERD. Clients with GERD should sleep with the head of the bed elevated 6 to 8 inches or sleep on their left side to reduce nighttime reflux.
7. A nurse is contributing to the plan of care for a client who is 2 days postoperative and reports pain in their calf. Which of the following actions should the nurse include?
  • Instruct the client to massage the calf gently.

  • Maintain the leg in a dependent position while in bed.

  • Monitor the client's pulse oximetry.

  • Apply a cold compress to the client's calf.

Explanation

Explanation
A postoperative client reporting calf pain is a classic sign of deep vein thrombosis (DVT). The priority concern with DVT is the risk of a pulmonary embolism (PE), where a clot may travel to the lungs. Monitoring pulse oximetry helps detect early signs of decreased oxygen saturation, which could indicate a pulmonary embolism — a life-threatening complication.
Correct Answer Is:
(C) Monitor the client's pulse oximetry
Why the other options are incorrect:
A. Instruct the client to massage the calf gently Massaging a potentially clotted calf is contraindicated as it can dislodge the clot and cause a pulmonary embolism.
B. Maintain the leg in a dependent position while in bed A dependent position increases venous pooling and worsens DVT. The leg should be elevated to promote venous return.
D. Apply a cold compress to the client's calf Cold compresses are not the appropriate intervention for suspected DVT and do not address the underlying concern of clot formation or embolization.
8. A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following findings should the nurse recognize as an adverse effect of this medication?
  • Hypoglycemia

  • Hypokalemia

  • Hyperchloremia

  • Hypernatremia

Explanation

Explanation
Correct Answer: (B) Hypokalemia
Furosemide is a loop diuretic that promotes the excretion of water, sodium, and potassium through the kidneys. Because potassium is lost along with fluid, hypokalemia (low potassium) is a well-known and common adverse effect. The nurse should monitor potassium levels closely and watch for signs such as muscle weakness, cramping, and cardiac dysrhythmias.
Why the other options are incorrect:
A. Hypoglycemia — Furosemide does not lower blood glucose. Hypoglycemia is associated with insulin or oral hypoglycemic agents, not loop diuretics.
C. Hyperchloremia — Furosemide actually promotes chloride excretion, which can lead to hypochloremia, not hyperchloremia.
D. Hypernatremia — While furosemide causes sodium excretion, it tends to cause hyponatremia rather than hypernatremia due to the loss of sodium in the urine.
9. A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
  • Observing the patency of an intravenous catheter on a stable client

  • Performing a gastrostomy feeding on a stable client

  • Providing postmortem care to a client

  • Changing a sterile dressing for a client who is postoperative

Explanation

Explanation
Correct Answer: (C) Providing postmortem care to a client
Postmortem care involves bathing and preparing the body after death, which is a task that does not require clinical judgment or nursing assessment. It is within the scope of practice of assistive personnel (AP) and is an appropriate task to delegate as it involves routine physical care rather than clinical decision-making.
Why the other options are incorrect:
A. Observing the patency of an intravenous catheter on a stable client While APs can perform basic observations, assessing IV catheter patency requires clinical judgment to identify complications such as infiltration or phlebitis, which is within the nurse's scope of practice.

B. Performing a gastrostomy feeding on a stable client Gastrostomy tube feedings involve clinical knowledge and monitoring for complications such as aspiration or tube displacement. This task requires nursing assessment and should not be delegated to an AP.

D. Changing a sterile dressing for a client who is postoperative Sterile dressing changes require aseptic technique, wound assessment, and clinical judgment. This is a nursing responsibility and is not appropriate to delegate to assistive personnel.
10. A nurse is caring for a client who is incontinent of urine. Which of the following actions should the nurse take?
  • Apply barrier cream to the client's cleansed skin.

  • Apply a thin layer of cornstarch to the client's skin.

  • Keep the client's skin area moist.

  • Rinse the client's skin with hot water.

Explanation

Explanation
Barrier cream protects the skin from prolonged exposure to moisture and the irritating effects of urine, which can quickly break down skin integrity and lead to incontinence-associated dermatitis and pressure injuries. After cleansing the skin, applying a moisture barrier cream is the evidence-based standard for incontinence skin care.
Why the other options are incorrect:
B. Apply a thin layer of cornstarch to the client's skin — Cornstarch is not recommended for incontinence care as it can promote fungal growth in moist environments, worsening skin breakdown rather than protecting against it.
C. Keep the client's skin area moist — Keeping the skin moist is counterproductive and harmful. The goal of incontinence skin care is to keep the skin clean and dry to prevent maceration and breakdown.
D. Rinse the client's skin with hot water — Hot water can damage fragile skin, especially in older adults or those with sensitive skin. Lukewarm water should be used for gentle cleansing to avoid burns or further skin irritation.

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