Questions and Answers | Complete ATI Comprehensive Predictor Mastery
Study Guide with Verified Solutions, Detailed Rationales, Medical-Surgical
Nursing, Pharmacology, Fundamentals of Nursing, Maternal-Newborn
Nursing, Pediatric Nursing, Mental Health Nursing, Leadership and
Management, Community Health Nursing, Prioritization, Delegation,
Patient Safety, Infection Control, NGN Clinical Judgment Case Studies, ATI
Remediation and NCLEX-RN Success Preparation
Question 1: A nurse is caring for a client diagnosed with Clostridioides difficile
infection. Which infection control measure is the priority?
A. Using an alcohol-based hand sanitizer before and after patient care
B. Placing the client in a negative-pressure isolation room
C. Washing hands with soap and water before and after patient care
D. Wearing a fit-tested N95 respirator upon entering the room
CORRECT ANSWER: C. Washing hands with soap and water before and after patient
care
Rationale: C. difficile forms spores that are not destroyed by alcohol-based hand
sanitizers. Mechanical friction with soap and water is required to remove the spores
from the hands.
Question 2: A nurse is assessing a client who is 2 hours postoperative following a
total hip arthroplasty. Which finding requires immediate intervention?
A. Pain rated 4 out of 10 on a pain scale
B. Shortening and external rotation of the affected leg
C. A small amount of serosanguinous drainage on the dressing
D. Urine output of 35 mL/hr
CORRECT ANSWER: B. Shortening and external rotation of the affected leg
Rationale: Shortening and external rotation of the affected leg are classic signs of hip
prosthesis dislocation, which is a medical emergency requiring immediate provider
notification and intervention.
Question 3: A nurse is reviewing the medication administration record for a client
with heart failure. Which finding indicates digoxin toxicity?
A. Heart rate of 52/min and reports of yellow-tinted vision
B. Blood pressure of 145/90 mm Hg and headache
C. Respiratory rate of 22/min and productive cough
D. Urine output of 50 mL/hr and peripheral edema
CORRECT ANSWER: A. Heart rate of 52/min and reports of yellow-tinted vision
Rationale: Digoxin toxicity commonly presents with bradycardia (heart rate < 60/min),
gastrointestinal distress, and visual disturbances such as seeing yellow-green halos.
,Question 4: A nurse is caring for a client receiving a continuous IV infusion of
magnesium sulfate for severe preeclampsia. Which assessment finding indicates
magnesium toxicity?
A. Deep tendon reflexes of +2
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mm Hg
CORRECT ANSWER: B. Respiratory rate of 10/min
Rationale: Magnesium sulfate is a central nervous system depressant. A respiratory rate
less than 12/min indicates toxicity and requires immediate cessation of the infusion and
administration of calcium gluconate.
Question 5: A nurse is caring for a toddler diagnosed with epiglottitis. Which action
is contraindicated?
A. Keeping the child in a tripod position
B. Administering humidified oxygen
C. Inspecting the throat with a tongue depressor
D. Preparing for possible endotracheal intubation
CORRECT ANSWER: C. Inspecting the throat with a tongue depressor
Rationale: Inserting a tongue depressor or any object into the throat of a child with
epiglottitis can trigger a laryngospasm and complete airway obstruction.
Question 6: A charge nurse is delegating tasks for the upcoming shift. Which task is
appropriate to delegate to an assistive personnel (AP)?
A. Assessing a client's surgical incision for signs of infection
B. Ambulating a client who is 1 day postoperative following a knee replacement
C. Administering an oral dose of acetaminophen to a client with a headache
D. Teaching a client how to use an incentive spirometer
CORRECT ANSWER: B. Ambulating a client who is 1 day postoperative following a
knee replacement
Rationale: Ambulating a stable postoperative client is within the scope of practice for
assistive personnel. Assessment, medication administration, and teaching are nursing
responsibilities.
Question 7: A nurse is caring for a client prescribed warfarin. Which laboratory
value should the nurse monitor to determine the therapeutic effect of this
medication?
A. Activated partial thromboplastin time (aPTT)
B. International Normalized Ratio (INR)
,C. Platelet count
D. Hemoglobin and hematocrit
CORRECT ANSWER: B. International Normalized Ratio (INR)
Rationale: Warfarin is monitored using the PT/INR. The therapeutic INR for most
conditions is between 2.0 and 3.0. aPTT is used to monitor heparin therapy.
Question 8: A nurse is assessing a client 4 hours postpartum. The nurse notes the
fundus is boggy and displaced to the right. What is the nurse's first action?
A. Administer prescribed oxytocin IV
B. Assist the client to the bathroom to void
C. Perform vigorous fundal massage
D. Notify the health care provider immediately
CORRECT ANSWER: B. Assist the client to the bathroom to void
Rationale: A boggy, displaced fundus is often caused by a distended bladder. Assisting
the client to void is the least invasive and most appropriate first action to allow the
uterus to contract.
Question 9: A nurse is reviewing the fetal heart rate monitor of a client in labor. The
nurse notes late decelerations. Which action should the nurse take first?
A. Increase the rate of the maintenance IV fluid
B. Reposition the client to a lateral position
C. Administer oxygen via face mask at 10 L/min
D. Prepare the client for an emergency cesarean birth
CORRECT ANSWER: B. Reposition the client to a lateral position
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
improve placental blood flow by repositioning the client to a lateral (side-lying) position.
Question 10: A nurse is caring for a school-age child with asthma. The nurse should
administer albuterol before fluticasone for which reason?
A. Fluticasone decreases the effectiveness of albuterol.
B. Albuterol opens the airways, allowing fluticasone to be absorbed more effectively.
C. Albuterol prevents the oral candidiasis associated with fluticasone.
D. Fluticasone must be given on an empty stomach.
CORRECT ANSWER: B. Albuterol opens the airways, allowing fluticasone to be
absorbed more effectively.
Rationale: Albuterol is a short-acting beta-agonist that acts as a bronchodilator.
Administering it first opens the airways, maximizing the delivery and absorption of the
corticosteroid (fluticasone).
, Question 11: A nurse is caring for a client with a chest tube connected to a water-
seal drainage system. Which finding indicates the system is functioning correctly?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber with respirations
C. Constant bubbling in the suction control chamber
D. Absence of drainage in the collection chamber
CORRECT ANSWER: B. Tidaling in the water-seal chamber with respirations
Rationale: Tidaling (fluctuation of the fluid level with inspiration and expiration) in the
water-seal chamber indicates that the system is patent and functioning properly.
Continuous bubbling indicates an air leak.
Question 12: A nurse is preparing to administer a blood transfusion. Which action is
the priority before starting the transfusion?
A. Prime the IV tubing with normal saline.
B. Verify the blood product with another nurse.
C. Take the client's baseline vital signs.
D. Ensure the client has signed the informed consent.
CORRECT ANSWER: B. Verify the blood product with another nurse.
Rationale: Verifying the blood product, client identity, and blood type with another
licensed nurse is the critical safety step to prevent a fatal hemolytic transfusion
reaction.
Question 13: A nurse is caring for a client with a nasogastric (NG) tube. Which
method is the most reliable for verifying initial tube placement?
A. Auscultating a whoosh of air over the epigastrium
B. Testing the pH of the gastric aspirate
C. Obtaining an abdominal x-ray
D. Observing for respiratory distress during insertion
CORRECT ANSWER: C. Obtaining an abdominal x-ray
Rationale: An abdominal x-ray is the gold standard and most reliable method for
confirming initial NG tube placement before initiating feedings or medications.
Question 14: A nurse is assessing a client with a traumatic brain injury. Which
finding is an early indication of increased intracranial pressure (ICP)?
A. Bradycardia
B. Widening pulse pressure
C. Restlessness and irritability
D. Fixed and dilated pupils
CORRECT ANSWER: C. Restlessness and irritability