ATI LPN
ATI PN Comprehensive Predictor 2024
1. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?
- A. Monitor the site for further swelling
- B. Remove the catheter and place it in another site
- C. Reduce the flow rate of IV fluids
- D. Switch to oral hydration
Correct answer: B
Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.
2. A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?
- A. Ask the client's full name
- B. Scan the client's facility identification band
- C. Call the client's name
- D. Verify with a second nurse
Correct answer: B
Rationale: The correct action to verify a client's identity when administering medications is to scan the client's facility identification band. This method ensures accuracy and helps prevent medication errors. Asking the client's full name (Choice A) may not be reliable as names can be similar, leading to confusion. Calling the client's name (Choice C) may not be effective if there are multiple clients with the same name in the facility. Verifying with a second nurse (Choice D) is an important safety measure for certain tasks but is not specifically for verifying a client's identity.
3. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
- A. Wear sterile gloves when removing the old dressing
- B. Warm the irrigation solution to 40.5°C (105°F)
- C. Cleanse the wound from the center outwards
- D. Use a 20 mL syringe to irrigate the wound
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with a prescription for wound irrigation is to cleanse the wound from the center outwards. This technique helps prevent contamination by pushing debris away from the wound rather than into it. Choice A is incorrect because wearing sterile gloves is important during wound care but not specifically mentioned for wound irrigation. Choice B is incorrect because warming the irrigation solution to a specific temperature is not a standard recommendation and can potentially harm the client. Choice D is incorrect because the size of the syringe may vary based on the wound size and depth, so using a 20 mL syringe is not a universal guideline.
4. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct answer: D
Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.
5. A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid if you experience gastrointestinal upset.
- B. You should limit your caffeine intake while taking this medication.
- C. This medication may cause your urine to turn dark brown.
- D. You should avoid taking this medication with dairy products.
Correct answer: D
Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.
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