LPN LPN
ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?
- A. Use restraints to prevent the client from getting out of bed
- B. Encourage family members to stay with the client at all times
- C. Use a bed exit alarm system
- D. Keep the client's room dark and quiet to reduce stimulation
Correct answer: C
Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.
2. A nurse is reviewing the plan of care for a client undergoing radiation therapy for cancer. Which of the following instructions should the nurse reinforce with the client?
- A. Apply sunscreen before going outside
- B. Avoid using perfumed lotions
- C. Massage the area daily
- D. Take vitamin supplements with food
Correct answer: B
Rationale: The correct instruction the nurse should reinforce with the client undergoing radiation therapy is to avoid using perfumed lotions. This is essential to reduce the risk of skin irritation, as perfumed lotions can exacerbate skin reactions during radiation therapy. Applying sunscreen before going outside is generally a good practice but not specifically related to radiation therapy. Massaging the area daily is contraindicated during radiation therapy as it can further irritate the skin. Taking vitamin supplements with food is important for overall health but is not a specific instruction related to radiation therapy.
3. What is the primary action the nurse should take first for a client with a pressure ulcer who has a serum albumin level of 3 g/dL?
- A. Increase the protein intake in the diet
- B. Consult with a dietitian to create a high-protein diet
- C. Increase the IV fluid infusion rate
- D. Administer a protein supplement
Correct answer: B
Rationale: The correct answer is to consult with a dietitian to create a high-protein diet. A serum albumin level of 3 g/dL indicates hypoalbuminemia, which can impair wound healing. Consulting with a dietitian to optimize the client's protein intake is crucial in promoting wound healing for pressure ulcers. Increasing the protein intake in the diet (Choice A) may not be sufficient without proper guidance from a dietitian. Increasing the IV fluid infusion rate (Choice C) is not directly related to addressing the protein deficiency. Administering a protein supplement (Choice D) should be guided by a healthcare professional's recommendation after consulting with a dietitian.
4. What is the first step in managing a patient with a suspected pneumothorax?
- A. Insert a chest tube
- B. Monitor respiratory status
- C. Administer oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.
5. What are the early signs and symptoms of sepsis?
- A. Increased heart rate and fever
- B. Low blood pressure and confusion
- C. Rapid breathing and sweating
- D. Abdominal pain and cyanosis
Correct answer: A
Rationale: The correct answer is A: Increased heart rate and fever. In sepsis, an increased heart rate and fever are common early signs of systemic infection. While choices B, C, and D can be present in later stages of sepsis, they are not typically the initial signs. Low blood pressure and confusion may occur in severe sepsis or septic shock. Rapid breathing and sweating can be seen as sepsis progresses. Abdominal pain and cyanosis may develop as the condition advances but are not usually the earliest signs.
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