ATI NCLEX PN Predictor Test

Correct Answer: A

Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.

Correct Answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

Correct Answer: A

Rationale: Correct answer: The most appropriate management for a patient with congestive heart failure is to administer diuretics to help remove excess fluid and monitor fluid balance. Diuretics help reduce the workload on the heart and alleviate symptoms of fluid overload. Choice B is incorrect because patients with congestive heart failure are usually advised to limit sodium intake and carefully monitor fluid intake. Choice C is incorrect because although oxygen therapy may be necessary in certain cases, it is not the primary management for congestive heart failure. Pain relief is not a primary intervention for this condition. Choice D is incorrect because bronchodilators are not the first-line treatment for congestive heart failure. Encouraging mobility is important, but administering diuretics and monitoring fluid balance take precedence in managing this condition.

Correct Answer: B

Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.

Correct Answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.