LPN LPN
ATI PN Comprehensive Predictor
1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?
- A. Chills
- B. Bradycardia
- C. Hypertension
- D. Low back pain
Correct answer: D
Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.
2. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?
- A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
- B. Reinforcing teaching with a client who is learning to walk with a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.
3. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.
4. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
- A. Abdominal pain radiating to the right shoulder.
- B. Absent bowel sounds.
- C. Brown drainage on the surgical dressing.
- D. Urine output of 25 mL/hr.
Correct answer: D
Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.
5. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?
- A. Ensure the client has cotton bedding
- B. Keep the oxygen equipment away from heat sources
- C. Use wool blankets to ensure warmth
- D. Allow the client to use electronic devices near the oxygen supply
Correct answer: B
Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.
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