ATI Comprehensive Predictor PN

Correct Answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

Correct Answer: B

Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.

Correct Answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

Correct Answer: B

Rationale: The best intervention for managing dehydration is to monitor fluid and electrolyte levels. This approach allows healthcare providers to assess the severity of dehydration, determine appropriate fluid replacement therapy, and prevent complications. Administering antiemetics (Choice A) may help with nausea but does not address the underlying issue of dehydration. Encouraging the client to drink more fluids (Choice C) may be appropriate for mild dehydration but can be inadequate for moderate to severe cases. Administering intravenous fluids (Choice D) is crucial for severe dehydration or cases where oral rehydration is ineffective, but monitoring fluid and electrolyte levels should precede this intervention.

Correct Answer: D

Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.