ATI NCLEX PN Predictor Test

Correct Answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

Correct Answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

Correct Answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

Correct Answer: A

Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.

Correct Answer: A

Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.