LPN LPN
ATI PN Comprehensive Predictor 2020
1. What is the most important intervention for a client with delirium?
- A. Administer sedative medication
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Increase environmental stimulation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.
2. What are the principles of aseptic technique in wound care?
- A. Use sterile gloves and a clean dressing
- B. Apply a clean dressing using sterile scissors
- C. Wash hands thoroughly before applying the dressing
- D. Use a clean glove and avoid contact with the wound
Correct answer: A
Rationale: The correct answer is A: 'Use sterile gloves and a clean dressing.' Aseptic technique in wound care requires the use of sterile gloves to prevent infection. Choice B is incorrect as the method of application does not primarily focus on maintaining asepsis. Choice C, while important for infection control, is not specific to aseptic technique in wound care. Choice D is incorrect because using a single clean glove does not ensure the level of sterility needed for aseptic wound care.
3. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?
- A. Limit social interactions
- B. Demonstrate assertiveness
- C. Follow a rigid schedule
- D. Perform deep breathing exercises
Correct answer: B
Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.
4. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?
- A. Keep the bed in the lowest position
- B. Raise all four side rails to prevent falls
- C. Assist with ambulation every 2 hours
- D. Use a bed exit alarm to notify staff of attempts to leave the bed
Correct answer: D
Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.
5. How should a healthcare professional assess a patient with a suspected infection?
- A. Monitor temperature and check for elevated white blood cells
- B. Monitor blood pressure and check for fever
- C. Assess for changes in mental status and monitor urine output
- D. Administer antibiotics and monitor for changes in mental status
Correct answer: A
Rationale: When assessing a patient with a suspected infection, it is crucial to monitor temperature and check for elevated white blood cells. Elevated temperature indicates a potential infection, and increased white blood cells are a sign of inflammation and the body's response to an infection. Monitoring blood pressure (choice B) and checking for fever (choice B) are not as specific indicators of infection as monitoring temperature and white blood cell count. Assessing changes in mental status and monitoring urine output (choice C) are important aspects of patient assessment but may not directly indicate a suspected infection. Administering antibiotics (choice D) should only be done after a confirmed diagnosis of a bacterial infection, as unnecessary antibiotic use can lead to antibiotic resistance and other adverse effects.
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