LPN LPN
ATI PN Comprehensive Predictor
1. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?
- A. Increase the suction setting on the ventilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Encourage deep breathing exercises
Correct answer: B
Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.
2. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?
- A. Serum albumin level of 3 g/dL
- B. Braden scale score of 20
- C. Norton scale score of 18
- D. Hemoglobin level of 13 g/dL
Correct answer: A
Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.
3. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?
- A. Take your blood pressure after eating
- B. Sit quietly for 5 minutes before taking your blood pressure
- C. Use a blood pressure cuff that is too small
- D. Take your blood pressure while standing
Correct answer: B
Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.
4. A healthcare professional is reviewing the medical record of a client who is receiving furosemide. Which of the following laboratory values should the healthcare professional monitor while the client is taking this medication?
- A. Sodium
- B. Glucose
- C. Potassium
- D. Calcium
Correct answer: C
Rationale: The correct answer is C: Potassium. Furosemide is a diuretic that can cause potassium depletion due to increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Sodium (choice A) levels are not typically affected by furosemide. Glucose (choice B) monitoring is important with other medications like corticosteroids but is not directly related to furosemide use. Calcium (choice D) levels are not significantly impacted by furosemide.
5. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Encourage pursed-lip breathing
- C. Position the client in high Fowler's position
- D. Encourage deep breathing and coughing
Correct answer: B
Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.
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