LPN LPN
ATI Comprehensive Predictor PN
1. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?
- A. Use a bed exit alarm to notify staff of attempts to leave the bed
- B. Raise all four side rails for safety
- C. Encourage frequent ambulation with assistance
- D. Use restraints to prevent the client from getting out of bed
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.
2. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.
3. A client scheduled to begin chemotherapy is discussing alopecia with a nurse. Which of the following statements should the nurse make?
- A. Avoid washing your hair during treatment
- B. Your oncologist might prescribe a cold cap during treatment to reduce hair loss
- C. You'll need to apply sunscreen to the scalp
- D. You'll likely experience regrowth of hair within 6 months after treatment ends
Correct answer: B
Rationale: The correct answer is B. The nurse should inform the client that their oncologist might prescribe a cold cap during treatment to reduce chemotherapy-induced hair loss by cooling the scalp. Choice A is incorrect as washing the hair during treatment is generally recommended. Choice C is incorrect as sunscreen is not typically needed for the scalp in this context. Choice D is incorrect as regrowth of hair can vary among individuals and is not guaranteed within a specific timeframe.
4. How should a healthcare professional assess a patient with potential pneumonia?
- A. Assess lung sounds and monitor oxygen saturation
- B. Monitor for fever and sputum production
- C. Auscultate heart sounds and check for cyanosis
- D. Monitor for chest pain and administer oxygen
Correct answer: A
Rationale: Correctly assessing a patient with potential pneumonia involves listening to lung sounds and monitoring oxygen saturation. Lung sounds can reveal abnormal breath sounds associated with pneumonia, such as crackles or diminished breath sounds. Oxygen saturation monitoring helps in detecting respiratory distress, a common complication of pneumonia. Monitoring for fever and sputum production (Choice B) is important but not as specific as assessing lung sounds and oxygen saturation. Auscultating heart sounds and checking for cyanosis (Choice C) are not primary assessments for pneumonia. Monitoring for chest pain and administering oxygen (Choice D) are relevant interventions but do not address the initial assessment of pneumonia.
5. What are the key signs of respiratory distress?
- A. Increased respiratory rate and use of accessory muscles
- B. Decreased respiratory rate and cyanosis
- C. Cyanosis and use of accessory muscles
- D. Altered mental status and bradycardia
Correct answer: A
Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.
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