LPN LPN
ATI PN Comprehensive Predictor 2020 Answers
1. Which of the following is an early indicator that a client with a tracheostomy may require suctioning?
- A. Decreased respiratory rate
- B. Irritability
- C. Bradycardia
- D. Decreased oxygen saturation
Correct answer: B
Rationale: Irritability is an early indicator that suctioning is necessary for a client with a tracheostomy. Irritability can signal discomfort or difficulty breathing, which may be due to the need for suctioning to clear the airway. Decreased respiratory rate, bradycardia, and decreased oxygen saturation are not typically early indicators that suctioning is needed in a client with a tracheostomy. These symptoms may occur later if the airway is not cleared promptly.
2. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone
- B. The client has 1+ pedal edema in both feet at the end of the day
- C. The client complains of an increase in vaginal discharge
- D. The client says she feels pressure against her diaphragm when the baby moves
Correct answer: A
Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.
3. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?
- A. Assess for bladder distention after 4 hours
- B. Pour warm water over the perineum
- C. Restrict the client's oral fluid intake
- D. Restrict movement for at least 12 hours
Correct answer: B
Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.
4. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?
- A. Take this medication in the morning.
- B. Avoid drinking grapefruit juice.
- C. Increase your intake of leafy green vegetables.
- D. Monitor your pulse daily while taking this medication.
Correct answer: B
Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.
5. A client with peptic ulcer disease is being taught measures to prevent exacerbation of the condition. Which of the following instructions should the nurse include?
- A. Avoid consuming dairy products
- B. Limit alcohol consumption
- C. Use antacids frequently
- D. Drink coffee to improve digestion
Correct answer: B
Rationale: The correct answer is B: Limit alcohol consumption. Alcohol can irritate the stomach lining and worsen peptic ulcer disease. Avoiding dairy products is not necessary unless the client is lactose intolerant. Using antacids frequently may provide symptomatic relief but does not address the root cause of the condition. Drinking coffee can actually stimulate acid production and potentially aggravate peptic ulcers.
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