ATI Comprehensive Predictor PN

Correct Answer: A

Rationale: The best intervention to prevent falls in a client with dementia who gets out of bed unsupervised is to place a bed exit alarm. This device alerts staff when the client attempts to leave the bed, allowing timely intervention to reduce the risk of falls. Using restraints (choice B) can lead to physical and psychological harm and should be avoided unless absolutely necessary. Asking the client's family to stay at the bedside (choice C) may not be feasible at all times and does not provide a continuous monitoring solution. Encouraging frequent ambulation with assistance (choice D) is beneficial for mobility but may not address the immediate risk of falls associated with unsupervised bed exits.

Correct Answer: C

Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.

Correct Answer: B

Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.

Correct Answer: A

Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.

Correct Answer: D

Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.