LPN LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?
- A. Do not press the button during baby's movements
- B. You should depress the button when you feel your baby move
- C. Press the button only during contractions
- D. Do not eat before the test
Correct answer: B
Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.
2. 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.
3. A nurse is reviewing the medical record of a client who is taking furosemide. Which of the following findings should the nurse report to the provider?
- A. Potassium level of 3.8 mEq/L
- B. Sodium level of 135 mEq/L
- C. Magnesium level of 1.6 mEq/L
- D. Calcium level of 8.5 mg/dL
Correct answer: C
Rationale: The correct answer is C. A magnesium level of 1.6 mEq/L is within the normal range, but monitoring potassium levels is crucial for clients taking furosemide. Furosemide can cause hypokalemia (low potassium levels), which can lead to adverse effects such as cardiac dysrhythmias. Sodium and calcium levels are not typically affected by furosemide, so they are not the priority findings to report to the provider in this case.
4. 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.
5. 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.
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