LPN LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. What are the key nursing assessments for a patient receiving enteral feeding?
- A. Monitor gastric residual volume and check for abdominal distension
- B. Ensure the correct placement of the feeding tube
- C. Assess for signs of dehydration and electrolyte imbalances
- D. Elevate the head of the bed to prevent aspiration
Correct answer: A
Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.
2. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?
- A. Perform Kegel exercises daily
- B. Perform light exercise for 3 hours each day
- C. Avoid bathing for 3 days
- D. Avoid sitting in a chair for more than 2 hours
Correct answer: A
Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.
3. What are the nursing interventions for a patient with neutropenia?
- A. Monitor for signs of infection and administer antibiotics
- B. Isolate the patient and provide a low-microbial diet
- C. Monitor vital signs and avoid unnecessary invasive procedures
- D. Encourage the patient to engage in social activities
Correct answer: A
Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.
4. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraints to a non-moving part of the bed.
- C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
- D. Remove the client's restraints based on the client's condition.
Correct answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.
5. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?
- A. Ignore the behavior
- B. Reassign the AP
- C. Report the behavior to the manager
- D. Discuss this behavior with the AP while reinforcing expectations
Correct answer: D
Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.
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