LPN LPN
ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor the client's electrolyte levels daily
- B. Weigh the client daily
- C. Monitor the client's blood glucose levels every 6 hours
- D. Change the TPN tubing every 24 hours
Correct answer: D
Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.
2. Which lifestyle change should be emphasized for a client with hypertension?
- A. Increase sodium intake to prevent fluid retention
- B. Reduce sodium and caffeine intake
- C. Increase protein intake to promote muscle strength
- D. Increase intake of high-fat foods
Correct answer: B
Rationale: The correct answer is B: 'Reduce sodium and caffeine intake.' Clients with hypertension benefit from reducing sodium intake as it can help lower blood pressure levels. Caffeine also has a vasoconstrictive effect, which can increase blood pressure. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension due to fluid retention. While protein intake is important for overall health, it is not a primary focus in managing hypertension. Increasing intake of high-fat foods can lead to weight gain and negatively impact heart health, which is counterproductive for someone with hypertension.
3. A patient is being educated about a clear liquid diet. Which of the following should the nurse instruct the patient to avoid?
- A. Lemon-lime sports drinks
- B. Ginger ale
- C. Black coffee
- D. Orange sherbet
Correct answer: D
Rationale: The correct answer is D: Orange sherbet. A clear liquid diet consists of liquids that are transparent and easily digestible. Orange sherbet, being a frozen dessert, is not a clear liquid and should be avoided. Choices A, B, and C are all acceptable in a clear liquid diet. Lemon-lime sports drinks, ginger ale, and black coffee are clear liquids that can be included in the diet as they are transparent and leave little residue in the gastrointestinal tract, unlike orange sherbet.
4. A client with hypertension is receiving lifestyle education from a nurse. What should be emphasized?
- A. Encourage a low-sodium diet
- B. Advise the client to avoid caffeinated drinks
- C. Recommend increasing high-protein foods
- D. Advise the client to reduce fat intake
Correct answer: B
Rationale: The correct answer is to advise the client to avoid caffeinated drinks. Caffeine can temporarily increase blood pressure, so avoiding caffeinated drinks can help manage hypertension. Encouraging a low-sodium diet (Choice A) is essential for hypertension management as excess sodium can raise blood pressure. Increasing high-protein foods (Choice C) is not a primary focus in managing hypertension. While reducing fat intake (Choice D) can be beneficial for overall health, it is not the priority in lifestyle modifications for hypertension.
5. What is the correct way to assess for pitting edema?
- A. Press over the bony area for 5 seconds and release
- B. Press over the skin for 10 seconds and check for discoloration
- C. Press the area and check for the presence of rash
- D. Press the skin and assess for rebound tenderness
Correct answer: A
Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.
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