LPN LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?
- A. Medication history
- B. Fluid and electrolyte imbalances
- C. Psychosocial stressors
- D. Environmental factors
Correct answer: B
Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.
2. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?
- A. Position the client on their left side
- B. Irrigate the NG tube with sterile water
- C. Replace the NG tube with a new one
- D. Increase the suction setting to relieve the blockage
Correct answer: B
Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.
3. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?
- A. Implement a regular toileting schedule
- B. Encourage the client to wear athletic socks when ambulating
- C. Place all four bed rails in the upright position
- D. Require a family member to remain at the bedside
Correct answer: A
Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.
4. In the emergency department, a nurse is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?
- A. Below-the-knee amputation.
- B. 10 cm (4 in) laceration.
- C. Fractured tibia.
- D. 95% full-thickness body burn.
Correct answer: A
Rationale: A below-the-knee amputation requires immediate attention due to the risk of hemorrhage and shock, making it the highest priority. This type of injury can lead to significant blood loss and impaired perfusion, which can be life-threatening if not addressed promptly. While a 10 cm laceration, a fractured tibia, and a 95% full-thickness body burn are serious injuries requiring urgent care, they do not pose the same immediate threat to life as a below-the-knee amputation. The laceration may require suturing to control bleeding and prevent infection, the fractured tibia needs stabilization to prevent further damage and pain, and the burn necessitates immediate management to prevent complications, but they are not as acutely life-threatening as the amputation.
5. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse take?
- A. Use the Z-track method to administer the medication.
- B. Use a 1.5-inch needle to administer the medication.
- C. Use the deltoid muscle for the injection.
- D. Administer the injection at a 90° angle.
Correct answer: A
Rationale: The Z-track method should be used to administer IM injections in obese clients to prevent medication from leaking into subcutaneous tissue. Using a longer needle (1.5 inches) ensures that the medication reaches the muscle mass adequately. Choice C is incorrect because the deltoid muscle is not ideal for IM injections in obese clients due to inadequate muscle mass. Administering the injection at a 90° angle (perpendicular to the skin) is recommended for IM injections to ensure proper delivery into the muscle.
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