LPN LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. A client is having difficulty voiding after removal of an indwelling urinary catheter. What should the nurse do?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This action helps stimulate voiding post-catheterization by promoting relaxation and providing sensory input. Assessing for bladder distention after 6 hours (Choice A) is important but not the immediate intervention needed for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not effectively address the issue of post-catheterization voiding difficulty. Restricting the client's intake of oral fluids (Choice C) is not appropriate and can lead to dehydration, which is not helpful in promoting voiding.
2. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who was just given a glass of orange juice for a low blood glucose level.
- B. A client who is scheduled for a procedure in 1 hr.
- C. A client who has 100 mL fluid remaining in his IV bag.
- D. A client who received a pain medication 30 min ago for postoperative pain.
Correct answer: A
Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.
3. A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?
- A. Apply heat to the affected area
- B. Place the client in a prone position
- C. Turn and reposition the client every 2 hours
- D. Provide the client with a bedpan every 4 hours
Correct answer: C
Rationale: The correct intervention for a client at risk for pressure ulcers is to turn and reposition the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and reducing the risk of pressure ulcer development. Applying heat to the affected area (Choice A) can increase the risk of skin breakdown. Placing the client in a prone position (Choice B) can also increase pressure on certain areas, leading to pressure ulcers. Providing the client with a bedpan every 4 hours (Choice D) is not directly related to preventing pressure ulcers.
4. What are the signs of hypovolemic shock and what is the nurse's role in management?
- A. Rapid pulse, low blood pressure; administer IV fluids
- B. Cold extremities, rapid breathing; administer oxygen
- C. Decreased urine output, sweating; administer diuretics
- D. Weak pulse, clammy skin; administer vasopressors
Correct answer: A
Rationale: The correct signs of hypovolemic shock are a rapid pulse and low blood pressure. Administering IV fluids helps to restore circulating volume, which is essential in managing hypovolemic shock. Choice B is incorrect because cold extremities and rapid breathing are not typical signs of hypovolemic shock. Choice C is incorrect as administering diuretics would further decrease circulating volume, worsening the condition. Choice D is incorrect as administering vasopressors may further compromise perfusion in hypovolemic shock.
5. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?
- A. Use the cane on the weak side of the body
- B. Advance the cane and the strong leg simultaneously
- C. Maintain two points of support on the floor
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct answer: C
Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
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