LPN LPN
ATI PN Comprehensive Predictor 2024
1. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?
- A. Encourage the client to bear down
- B. Apply the external fetal monitor
- C. Provide the client with fluids
- D. Administer IV fluids
Correct answer: B
Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.
2. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?
- A. Decerebrate posturing.
- B. Hypervigilance.
- C. Absence of deep tendon reflexes.
- D. Glasgow Coma Scale score of 15.
Correct answer: A
Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.
3. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?
- A. Maintain the client's bed in the lowest position
- B. Use a bed exit alarm system
- C. Assist the client with ambulation every hour
- D. Raise all 4 side rails for safety
Correct answer: B
Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.
4. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
- A. You should not gain more than 10 lbs
- B. Your weight gain should be the same as for someone without diabetes
- C. Avoid gaining more than 15 lbs
- D. You should gain more weight because of your condition
Correct answer: B
Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.
5. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 150/80 mm Hg
- B. Swelling in the legs
- C. Persistent cough
- D. Heart rate of 72 beats per minute
Correct answer: C
Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.
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