ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
- A. Check the client's blood glucose level.
- B. Administer 10 units of insulin.
- C. Give the client a high-protein snack.
- D. Measure the client's blood pressure.
Correct answer: A
Rationale: The correct first action for a client presenting with confusion, sweating, and palpitations, suggestive of hypoglycemia, is to check the client's blood glucose level. This step helps to confirm if the symptoms are due to low blood sugar levels and guides appropriate interventions. Administering insulin without knowing the current blood glucose level can be dangerous and is not recommended as the initial step. Offering a high-protein snack may be necessary after confirming hypoglycemia, but checking the blood glucose level takes precedence. Measuring blood pressure is not the priority in this situation; addressing hypoglycemia is the immediate concern.
2. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread
- B. A sliced apple and red grapes
- C. A chocolate chip cookie with a glass of skim milk
- D. A scrambled egg with cheddar cheese
Correct answer: B
Rationale: The correct answer is B. Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. Foods high in phenylalanine such as peanut butter, wheat bread, chocolate chip cookies, milk, scrambled eggs, and cheddar cheese should be avoided. Sliced apples and red grapes are low in phenylalanine, making them safe choices for individuals with PKU. Choice A (peanut butter sandwich on wheat bread), Choice C (chocolate chip cookie with a glass of skim milk), and Choice D (scrambled egg with cheddar cheese) are all high in phenylalanine and should be avoided by individuals with PKU.
3. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?
- A. Providing pain management.
- B. Offering emotional support.
- C. Preventing infection.
- D. Initiating IV fluids.
Correct answer: D
Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.
4. A client is receiving discharge teaching after a total hip arthroplasty. Which of the following instructions should be included?
- A. Cross your legs at the ankles while sitting
- B. Avoid bending your hips more than 90 degrees
- C. Sit in a low-seated chair
- D. Twist your body when standing up
Correct answer: B
Rationale: To prevent dislocation of the hip prosthesis, the client should avoid bending their hips more than 90 degrees. Excessive bending at the hips can increase the risk of hip dislocation, which is a significant concern following total hip arthroplasty. Sitting with crossed legs at the ankles (choice A) can also increase the risk of hip dislocation and should be avoided. Sitting in a low-seated chair (choice C) can make it more challenging for the client to stand up safely. Twisting the body when standing up (choice D) can also strain the hip joint and increase the risk of dislocation. Therefore, the correct instruction to include during discharge teaching is to avoid bending the hips more than 90 degrees.
5. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?
- A. Provide clear instructions on how to ask for assistance
- B. Gradually resume self-care tasks, focusing on rest periods
- C. Encourage assistive personnel to complete self-care tasks
- D. Encourage the client to remain in bed until fully rested
Correct answer: B
Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.
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