ATI LPN
PN ATI Capstone Fundamentals Quiz
1. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct answer: A
Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.
2. What are the nursing interventions for a patient receiving anticoagulant therapy?
- A. Monitor INR levels and check for bleeding
- B. Administer antiplatelet therapy
- C. Check for signs of DVT and provide anticoagulation
- D. Administer aspirin and monitor for bleeding
Correct answer: A
Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.
3. While reviewing the medical record of a client with unstable angina, which of the following findings should the nurse report to the provider?
- A. BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min, Resp rate 26/min, urine output 90 mL/hr
- B. Skin is cool and moist with pallor
- C. Bilateral breath sounds with crackles heard at bases of lungs
- D. Creatinine kinase 100 units/L, C-reactive protein 0.8 mg/dL, Myoglobin 88 mcg/L
Correct answer: A
Rationale: The correct answer is A. The nurse should report these vital signs to the provider immediately as they indicate increased temperature, tachycardia, and tachypnea, which are signs of possible infection or systemic inflammatory response. This could exacerbate the client's unstable angina and needs prompt evaluation. Choices B, C, and D are not as urgent as the vital signs in option A and do not directly indicate a worsening condition in the context of unstable angina.
4. The delos Reyes couple have a 6-year-old child entering school for the first time. The delos Reyes family has a:
- A. Health threat
- B. Health deficit
- C. Foreseeable crisis
- D. Stress point
Correct answer: C
Rationale: The entry of the 6-year-old into school is a significant transition that can create an anticipated period of unusual demand on the family. This situation represents a foreseeable crisis as it involves a new experience that requires adjustment and adaptation from the family. It is not classified as a health threat, health deficit, or stress point, but rather a foreseeable crisis due to the expected challenges associated with a child starting school.
5. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?
- A. Use a tuberculin syringe.
- B. Insert the needle at a 45-degree angle.
- C. Use a 1-inch needle.
- D. Aspirate before injecting.
Correct answer: A
Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.
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