LPN LPN
ATI Comprehensive Predictor PN
1. 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.
2. How should a healthcare professional assess a patient with hyperkalemia?
- A. Monitor ECG and administer insulin
- B. Monitor blood glucose levels and provide fluids
- C. Monitor for muscle weakness and administer calcium gluconate
- D. Monitor electrolyte levels and provide potassium supplements
Correct answer: A
Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.
3. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?
- A. Use a phenol solution to clean the wound
- B. Place a warm compress over the wound
- C. Cleanse the wound from the center outwards
- D. Administer antibiotics prophylactically
Correct answer: C
Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.
4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Elevated blood glucose.
- B. Decreased urine output.
- C. Dependent edema.
- D. Jaundice.
Correct answer: C
Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.
5. What is the first step in preparing a blood transfusion?
- A. Administer the blood via IV push
- B. Verify the client's blood type before starting the transfusion
- C. Warm the blood to body temperature before administration
- D. Administer diuretics to prevent fluid overload
Correct answer: B
Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.
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