ATI Comprehensive Predictor NEWEST
2023-2024 ACTUAL TEST 180 QUESTIONS
AND CORRECT DETAILED ANSWERS
WITH RATIONALES|ALREADY GRADED
A
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I
went to the gym and worked out." The nurse should recognize the client is demonstrating which of the
following defense mechanisms? - correct answerSublimation
Rationale: The client is exhibiting behaviors consistent with sublimation, which is displayed when a client
substitutes socially unacceptable behavior for acceptable behavior.
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam.
Which of the following actions should the nurse take? - correct answerInitiate fall precautions for the
client
Rationale: The nurse should initiate fall precautions for a client who has a new prescription for
alprazolam because common adverse effects associated with this medication are orthostatic
hypotension, dizziness, confusion, and lethargy.
A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the following
findings should indicate to the nurse that the client has the ability to sign the informed consent? -
correct answerThe client is able to accurately describe the upcoming procedure
Rationale: The ability of the client to accurately describe the upcoming procedure indicates that the
provider adequately informed the client and that the client is able to sign the informed consent
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following
actions by the AP requires the nurse to intervene? - correct answerPlaces a pillow under the client's
right arm.
,Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of the left
shoulder.
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following
instructions should the nurse include? - correct answerIntroduce new foods one at a time over 5 to 7
days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions
should the nurse implement? - correct answerContact
Rationale: The nurse should implement contact precautions for a client who has an infection spread by
direct contact, such as MRSA.
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of
the following actions should the nurse take first - correct answerMassage the uterus to expel clots
Rationale: Using the EBP approach to client care, the nurse should identify that the priority action is
massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in
decreased bleeding.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following
statements should the nurse include in the teaching? - correct answer"Secure the retainer clip at the
level of your baby's armpits"
A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The
client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover
ostomy supplies. "Which of the following actions should the nurse take? (SATA) - correct answer-Refer
the client to a community based social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups
Rationale:
,-A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can
help the client face challenges with self-care and paying for necessary ostomy supplies
-A home health nurse can assist the client in learning to care for the colostomy as well as provide
medication management and emotional support
-A client who has cancer and a new colostomy can get help with coping from a support group and
possibly receive assistance obtaining supplies from local agencies
A nurse manager is reviewing unit records and discovers that client falls occur most frequently during
the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a
root cause analysis? - correct answerInvestigate environmental factors that might be contributing to
client injury during these hours.
Rationale: When conducting a root cause analysis, the nurse should look at the factors that could
possibly lead to the clients' falls. This can include environmental factors that might be causing the
problem.
A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest
occurs. Which of the following statements should the nurse make? - correct answer"I will provide you
with information about medical treatment to include in your living will"
Rationale: The nurses' responsibility is to provide the client with information about specific instructions
for addressing medical treatment in a living will. The nurse should assist the client while they are able to
make decisions for themself by providing information about what end-of-life preferences to document.
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse
expect? - correct answerRapid speech
Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech
patterns
A night shift nurse is giving a change of shift report to the day shift nurse on a client who is ready for
discharge. Which of the following information is the priority for the nurse to communicate to the
oncoming nurse? - correct answerThe client needs assistance when transferring from the bed to a
wheelchair.
, Rationale: The greatest risk to this client is injury due to a fall. Therefore, the priority information for the
nurse to communicate is that the client requires assistance during transfers.
A nurse is assessing a client during the immediate postpartum period. Which of the following findings
requires immediate intervention by the nurse? - correct answerBoggy uterus
Rationale: When using urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should
immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes
relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi
have formed at the placenta.
A nurse in an emergency department is preparing to discharge a client who has experienced intimate
partner violence. Which of the following actions should the nurse take first? - correct answerDevelop a
safety plan with the client
Rationale: The greatest risk to this client is injury from violence. Therefore, the first action the nurse
should take is to develop a safety plan with the client.
A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood
pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate
administering. - correct answerFlumazenil
Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor
antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to
support the client's respirations with a bag valve mask.
A home health nurse is planning care for an older adult client who has impaired vision. Which of the
following interventions should the nurse include in the plant of care to prevent injury in the home? -
correct answerMark the edges of the stairs for contrast
Rationale: Marking the edges of stairs with paint or colored tape for contrast can help older adult clients
who have impaired vision prevent injury by decreasing the risk of falls.
2023-2024 ACTUAL TEST 180 QUESTIONS
AND CORRECT DETAILED ANSWERS
WITH RATIONALES|ALREADY GRADED
A
A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I
went to the gym and worked out." The nurse should recognize the client is demonstrating which of the
following defense mechanisms? - correct answerSublimation
Rationale: The client is exhibiting behaviors consistent with sublimation, which is displayed when a client
substitutes socially unacceptable behavior for acceptable behavior.
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam.
Which of the following actions should the nurse take? - correct answerInitiate fall precautions for the
client
Rationale: The nurse should initiate fall precautions for a client who has a new prescription for
alprazolam because common adverse effects associated with this medication are orthostatic
hypotension, dizziness, confusion, and lethargy.
A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the following
findings should indicate to the nurse that the client has the ability to sign the informed consent? -
correct answerThe client is able to accurately describe the upcoming procedure
Rationale: The ability of the client to accurately describe the upcoming procedure indicates that the
provider adequately informed the client and that the client is able to sign the informed consent
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following
actions by the AP requires the nurse to intervene? - correct answerPlaces a pillow under the client's
right arm.
,Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of the left
shoulder.
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following
instructions should the nurse include? - correct answerIntroduce new foods one at a time over 5 to 7
days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions
should the nurse implement? - correct answerContact
Rationale: The nurse should implement contact precautions for a client who has an infection spread by
direct contact, such as MRSA.
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of
the following actions should the nurse take first - correct answerMassage the uterus to expel clots
Rationale: Using the EBP approach to client care, the nurse should identify that the priority action is
massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in
decreased bleeding.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following
statements should the nurse include in the teaching? - correct answer"Secure the retainer clip at the
level of your baby's armpits"
A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The
client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover
ostomy supplies. "Which of the following actions should the nurse take? (SATA) - correct answer-Refer
the client to a community based social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups
Rationale:
,-A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can
help the client face challenges with self-care and paying for necessary ostomy supplies
-A home health nurse can assist the client in learning to care for the colostomy as well as provide
medication management and emotional support
-A client who has cancer and a new colostomy can get help with coping from a support group and
possibly receive assistance obtaining supplies from local agencies
A nurse manager is reviewing unit records and discovers that client falls occur most frequently during
the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a
root cause analysis? - correct answerInvestigate environmental factors that might be contributing to
client injury during these hours.
Rationale: When conducting a root cause analysis, the nurse should look at the factors that could
possibly lead to the clients' falls. This can include environmental factors that might be causing the
problem.
A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest
occurs. Which of the following statements should the nurse make? - correct answer"I will provide you
with information about medical treatment to include in your living will"
Rationale: The nurses' responsibility is to provide the client with information about specific instructions
for addressing medical treatment in a living will. The nurse should assist the client while they are able to
make decisions for themself by providing information about what end-of-life preferences to document.
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse
expect? - correct answerRapid speech
Rationale: Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech
patterns
A night shift nurse is giving a change of shift report to the day shift nurse on a client who is ready for
discharge. Which of the following information is the priority for the nurse to communicate to the
oncoming nurse? - correct answerThe client needs assistance when transferring from the bed to a
wheelchair.
, Rationale: The greatest risk to this client is injury due to a fall. Therefore, the priority information for the
nurse to communicate is that the client requires assistance during transfers.
A nurse is assessing a client during the immediate postpartum period. Which of the following findings
requires immediate intervention by the nurse? - correct answerBoggy uterus
Rationale: When using urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should
immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes
relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi
have formed at the placenta.
A nurse in an emergency department is preparing to discharge a client who has experienced intimate
partner violence. Which of the following actions should the nurse take first? - correct answerDevelop a
safety plan with the client
Rationale: The greatest risk to this client is injury from violence. Therefore, the first action the nurse
should take is to develop a safety plan with the client.
A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood
pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate
administering. - correct answerFlumazenil
Rationale: The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor
antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to
support the client's respirations with a bag valve mask.
A home health nurse is planning care for an older adult client who has impaired vision. Which of the
following interventions should the nurse include in the plant of care to prevent injury in the home? -
correct answerMark the edges of the stairs for contrast
Rationale: Marking the edges of stairs with paint or colored tape for contrast can help older adult clients
who have impaired vision prevent injury by decreasing the risk of falls.
