LPN LPN
ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?
- A. Restrict the client's fluid intake.
- B. Monitor the client's deep-tendon reflexes.
- C. Place the client in the lithotomy position.
- D. Encourage the client to ambulate frequently.
Correct answer: B
Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.
2. 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.
3. A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?
- A. I will take this medication before meals
- B. I will mix this medication with water
- C. I will take this medication once a week
- D. I will rinse my mouth after taking this medication
Correct answer: D
Rationale: The correct answer is D because rinsing the mouth is essential to prevent staining and irritation caused by ferrous sulfate elixir. Choices A, B, and C are incorrect. Taking ferrous sulfate elixir before meals (Choice A) is not necessary. Mixing it with water (Choice B) is not recommended as it may alter the medication's effectiveness. Taking the medication once a week (Choice C) is incorrect as ferrous sulfate is usually prescribed daily or as directed by a healthcare provider.
4. A client has hyperthermia. Which of the following actions should the nurse take?
- A. Submerge the client's feet in ice water.
- B. Cover the client with a thermal blanket.
- C. Administer oral acetaminophen.
- D. Initiate seizure precautions.
Correct answer: C
Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.
5. 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.
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