ATI LPN
PN ATI Comprehensive Predictor
1. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
- A. Allow the client to sleep undisturbed
- B. Administer oxygen via facemask or nasal prongs
- C. Administer naloxone (Narcan)
- D. Place epinephrine 1:1,000 at the bedside
Correct answer: C
Rationale: The correct answer is to administer naloxone (Narcan). The client's vital signs indicate opioid-induced respiratory depression, which is a potential side effect of morphine. Naloxone is used to reverse the effects of opioids, particularly to restore normal respiratory function. Administering oxygen alone (Choice B) may not address the underlying cause of respiratory depression. Allowing the client to sleep undisturbed (Choice A) is inappropriate when signs of respiratory depression are present. Epinephrine (Choice D) is not indicated in this situation and is not used to reverse opioid effects.
2. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?
- A. Obtain a prescription for pain medication.
- B. Have the client stop and lie back down in bed.
- C. Report the complaint to the healthcare provider.
- D. Instruct the client to continue getting out of bed and into a chair.
Correct answer: B
Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain. Option A is incorrect as pain medication should not be the initial action for chest pain in CAD. Option C is incorrect because the nurse should first intervene directly to address the chest pain. Option D is incorrect as continuing the activity can worsen the myocardial ischemia and chest pain.
3. A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct answer: B
Rationale: A surge of energy is a common sign that precedes labor. This burst of energy, often referred to as the 'nesting instinct,' is believed to occur as the body prepares for labor, prompting the individual to undertake tasks to prepare for the arrival of the baby. Decreased vaginal discharge is not a typical sign preceding labor. Urinary retention is not a sign that precedes labor and may indicate another issue. Weight gain of 0.5 to 1.5 kg is not a specific sign of impending labor.
4. A new mother is learning to breastfeed her newborn. Which position is recommended for a mother recovering from a cesarean section?
- A. Cradle hold
- B. Football hold
- C. Side-lying position
- D. Cross-cradle hold
Correct answer: B
Rationale: The football hold is recommended for mothers recovering from a cesarean section because it positions the baby higher up and away from the incision site, avoiding pressure on the abdomen. This hold also provides better support for the baby's head and neck, making it a more comfortable position for both the mother and the newborn.
5. A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?
- A. Stop the TPN infusion.
- B. Notify the healthcare provider.
- C. Place the client in Trendelenburg position.
- D. Administer oxygen at 2 liters/minute.
Correct answer: C
Rationale: Placing the client in Trendelenburg position should be the initial action as it can help manage a suspected air embolism, a potential complication of TPN administration. This position helps trap air in the apex of the atrium, reducing the risk of air reaching the pulmonary circulation and causing further harm. Once the client is in a safe position, further actions such as stopping the TPN infusion, notifying the healthcare provider, and administering oxygen can be taken as appropriate.
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