ATI LPN
ATI NCLEX PN Predictor Test
1. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?
- A. Encourage the client to rest and let the healthcare team take over self-care tasks
- B. Instruct the client to gradually resume self-care tasks, with rest periods
- C. Assign assistive personnel to complete self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct answer: B
Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.
2. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?
- A. Supine with head elevated
- B. Lateral recumbent
- C. Prone with arms at sides
- D. Sitting with back rounded
Correct answer: B
Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.
3. A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?
- A. How severe is your pain on a scale of 1 to 10?
- B. Where is your pain located?
- C. What medication are you taking for the pain?
- D. When did the pain start?
Correct answer: B
Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.
4. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.
5. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
- A. Administer PRN haloperidol (Haldol) to decrease the need to walk
- B. Assess the client's gait for steadiness
- C. Restrain the client in a geriatric chair
- D. Administer PRN lorazepam (Ativan) to provide sedation
Correct answer: B
Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.
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