ATI LPN

1. A client with a history of substance abuse is admitted for detoxification. Which intervention is most important during the initial assessment?

• A. Obtain a detailed substance use history.
• B. Establish a trusting nurse-client relationship.
• C. Evaluate the client's physical health status.
• D. Determine the client's readiness for change.

Correct Answer: C

Rationale: Assessing the client's physical health status is the most critical intervention during the initial assessment of a client with a history of substance abuse who is admitted for detoxification. This evaluation helps identify and address any immediate health risks, such as withdrawal symptoms or medical complications, to ensure the client's safety and well-being during the detoxification process.

2. A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?

• A. Elevated blood pressure.
• B. Fever and chills.
• C. Increased urine output.
• D. Bradycardia.

Correct Answer: B

Rationale: Fever and chills are classic signs of a transfusion reaction. These symptoms indicate that the body is having a response to the transfused blood, possibly due to incompatibility or an immune reaction. It is crucial to recognize these signs promptly to prevent further complications and ensure appropriate management.

3. A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?

• A. Decreased libido is a common side effect of SSRIs and may improve over time.
• B. I will notify your healthcare provider to discuss possible medication changes.
• C. You should take your medication with food to reduce side effects.
• D. Increase your daily exercise to help manage this side effect.

Correct Answer: B

Rationale: When a client reports experiencing decreased libido while taking SSRIs, it is important for the nurse to notify the healthcare provider to discuss potential medication adjustments. This side effect can significantly impact a client's quality of life and addressing it promptly by involving the healthcare provider is crucial in providing holistic care.

4. The healthcare provider is caring for a patient who is taking warfarin (Coumadin). Which laboratory value should the healthcare provider monitor closely?

• A. Platelet count.
• B. Prothrombin time (PT).
• C. Hemoglobin level.
• D. White blood cell count.

Correct Answer: B

Rationale: Monitoring prothrombin time (PT) is essential for patients taking warfarin to assess the blood's ability to clot properly. This monitoring helps ensure that the patient maintains therapeutic levels of anticoagulation while minimizing the risk of bleeding complications.

5. A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?

• A. Report any signs of infection, such as sore throat or fever, to your healthcare provider.'
• B. Increase your intake of iodine-rich foods, such as seafood and dairy products.'
• C. Take the medication on an empty stomach for better absorption.'
• D. You may experience weight gain and fatigue as side effects of the medication.'

Correct Answer: A

Rationale: Propylthiouracil (PTU) can suppress bone marrow function, increasing the risk of infection, so it is important to report signs of infection promptly.