LPN LPN
ATI PN Comprehensive Predictor 2024
1. How do you assess for dehydration in a pediatric patient?
- A. Check for dry mouth and decreased urine output
- B. Monitor skin turgor and capillary refill
- C. Assess for lethargy and irritability
- D. Monitor blood pressure and heart rate
Correct answer: A
Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.
2. Which of the following is an early indication that a tracheostomy client requires suctioning?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased respiratory rate
Correct answer: B
Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.
3. A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?
- A. Avoid massaging the site after injection
- B. Massage the site after injection
- C. Use a circular motion to rub the site
- D. Apply a bandage after injecting
Correct answer: A
Rationale: The correct action for the nurse to take after administering an influenza virus immunization by the intradermal route is to avoid massaging the site. Massaging the site can spread the vaccine, potentially reducing its effectiveness. Rubbing the site in a circular motion or applying a bandage are not recommended actions as they can also interfere with the proper absorption of the vaccine.
4. A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?
- A. Avoid using a walker while walking.
- B. Keep the hip flexed at 90° while sitting.
- C. Place a pillow between your legs when turning.
- D. Cross your legs at the ankles when sitting.
Correct answer: C
Rationale: Placing a pillow between the legs is essential post-total hip arthroplasty to prevent adduction of the hip joint, reducing the risk of dislocation. Choices A, B, and D are incorrect. Using a walker while walking is encouraged for support and stability. Keeping the hip flexed at 90° while sitting can increase the risk of hip dislocation. Crossing legs at the ankles when sitting may also lead to hip dislocation.
5. A nurse is reinforcing teaching about a clear liquid diet. What should the client avoid?
- A. Lemon-lime sports drinks
- B. Orange sherbet
- C. Black coffee
- D. Ginger ale
Correct answer: D
Rationale: The correct answer is D, Ginger ale. A clear liquid diet includes fluids that are see-through and easily digestible. Ginger ale is a carbonated beverage that is allowed on a clear liquid diet. Orange sherbet, choice B, is not suitable for a clear liquid diet as it contains dairy products and solid particles, which are not transparent. Lemon-lime sports drinks, choice A, may contain added colorings or particles that are not allowed on a clear liquid diet. Black coffee, choice C, is also not recommended on a clear liquid diet as it is not a clear liquid and contains substances that may be hard to digest.
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