LPN LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. What are the risk factors for the development of pressure ulcers, and how can they be prevented?
- A. Immobility and poor nutrition
- B. Increased mobility and proper hygiene
- C. Excess moisture and lack of movement
- D. Frequent turning and repositioning
Correct answer: A
Rationale: The correct answer is A: Immobility and poor nutrition are significant risk factors for pressure ulcers. Immobility leads to prolonged pressure on certain body areas, increasing the risk of tissue damage. Poor nutrition can impair skin integrity and the body's ability to heal. Prevention strategies include frequent turning and repositioning to relieve pressure points. Choice B is incorrect because increased mobility actually reduces the risk of pressure ulcers. Choice C is incorrect as excess moisture can contribute to skin breakdown, but it is not a primary risk factor. Choice D is incorrect as frequent turning and repositioning are part of the prevention measures, not risk factors.
2. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?
- A. Encourage ambulation
- B. Apply ice packs
- C. Restrict the client's fluid intake
- D. Administer stool softeners
Correct answer: B
Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.
3. What is the most appropriate next step when a client with an NG tube attached to low suctioning becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions?
- A. Increase the suction pressure
- B. Irrigate the NG tube with sterile water
- C. Turn the client on their side
- D. Replace the NG tube with a new one
Correct answer: B
Rationale: The correct answer is to irrigate the NG tube with sterile water. When a client with an NG tube attached to low suctioning becomes nauseated and there is a decrease in the flow of gastric secretions, it indicates a possible blockage in the tube. Irrigating the tube with sterile water can help clear the blockage, allowing for proper suctioning and relieving the client's nausea. Increasing the suction pressure (Choice A) can further worsen the issue by potentially causing harm to the client. Turning the client on their side (Choice C) may not address the underlying problem of tube blockage. Replacing the NG tube with a new one (Choice D) should only be considered if other interventions, like irrigation, fail to clear the blockage.
4. What is the best teaching point for a client with left-leg weakness learning to use a cane?
- A. Use the cane on the weaker side
- B. Maintain two points of support on the floor at all times
- C. Advance the cane 30 to 45 cm with each step
- D. Advance the cane and the strong leg together
Correct answer: B
Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.
5. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?
- A. Facilitate the client in returning to usual activities of daily living
- B. Maintain optimal function within the client's limitations
- C. Assist the client in preparing for a peaceful and dignified death
- D. Delay the progression of the disease process in the client
Correct answer: B
Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.
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