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. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?
- A. High blood pressure
- B. Decreased bowel sounds
- C. Constipation
- D. Difficulty urinating
Correct answer: D
Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.
3. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?
- A. Move both crutches up first
- B. Step up with the unaffected leg first
- C. Lean forward on the crutches before stepping up
- D. Hold onto the handrail for support
Correct answer: B
Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.
4. How should a healthcare professional assess a patient with dehydration?
- A. Monitor skin turgor and check urine output
- B. Assess for jugular venous distention
- C. Auscultate lung sounds and monitor for fever
- D. Monitor for cyanosis and increased respiratory rate
Correct answer: A
Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.
5. What is the proper technique for obtaining a blood specimen from a central venous line?
- A. Use sterile gloves and discard the first 10 mL of blood
- B. Flush the line with heparin and then draw the specimen
- C. Draw the specimen and then administer heparin
- D. Use non-sterile gloves to reduce contamination risk
Correct answer: A
Rationale: The correct technique for obtaining a blood specimen from a central venous line is to use sterile gloves and discard the first 10 mL of blood. This practice helps ensure that the blood sample collected is not contaminated. Choice B is incorrect because flushing the line with heparin before drawing the specimen can contaminate the sample. Choice C is incorrect as administering heparin before drawing the specimen can affect the accuracy of the blood sample. Choice D is incorrect as using non-sterile gloves increases the risk of contamination, which is not recommended when obtaining a blood specimen from a central venous line.
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