ATI LPN
ATI PN Comprehensive Predictor 2024
1. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
- A. Apply counter-pressure for back pain
- B. Use deep breathing exercises
- C. Visualize the baby's head
- D. Use massage therapy
Correct answer: A
Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.
2. A healthcare provider is providing education on the use of clozapine. Which of the following should be included?
- A. Monitor for agranulocytosis
- B. It is a first-line treatment
- C. It can cause significant weight loss
- D. It has no risk for metabolic syndrome
Correct answer: A
Rationale: Correct Answer: A nurse should include monitoring for agranulocytosis when educating a patient about clozapine. Clozapine is known to cause agranulocytosis, a potentially life-threatening decrease in white blood cells. This adverse effect requires close monitoring to detect it early. Choices B, C, and D are incorrect because clozapine is not a first-line treatment for most conditions, it is more commonly associated with weight gain rather than weight loss, and it is known to have a risk for metabolic syndrome.
3. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?
- A. Monitor for changes in level of consciousness
- B. Check for pupil dilation
- C. Assess for bradycardia
- D. Monitor for vomiting
Correct answer: A
Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.
4. A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct answer: D
Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT. Applying a warm compress (Choice A) could worsen the condition by increasing blood flow. Elevating the leg (Choice B) might be contraindicated in DVT as it can dislodge a clot. Measuring the circumference of the leg (Choice C) is not the priority at this time compared to promptly involving the healthcare provider.
5. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
- A. Assess the infant's bilirubin levels
- B. Initiate phototherapy
- C. Monitor the infant's temperature
- D. Encourage breastfeeding
Correct answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.
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