ATI LPN
ATI PN Comprehensive Predictor
1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?
- A. Chills
- B. Bradycardia
- C. Hypertension
- D. Low back pain
Correct answer: D
Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.
2. What is the most appropriate safety measure for a client using home oxygen?
- A. Store oxygen tanks upright when not in use
- B. Ensure oxygen tanks are kept upright at all times
- C. Allow family members to smoke in designated areas
- D. Keep oxygen equipment at least 10 feet away from heat sources
Correct answer: B
Rationale: The correct answer is to ensure oxygen tanks are kept upright at all times. This is important to prevent the tanks from falling over, which can lead to injuries or tank damage. Choice A is incorrect because oxygen tanks should not be stored in a closet when not in use, as this can lead to poor ventilation and potential hazards. Choice C is incorrect because smoking near oxygen tanks poses a significant fire risk. Choice D is incorrect because while it is important to keep oxygen equipment away from heat sources, ensuring the tanks are kept upright is a more critical safety measure.
3. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD. In COPD, the airways are narrowed, causing difficulty in breathing, leading to increased work of breathing. Normal respiratory rate and clear lung sounds are less likely findings in a client with COPD experiencing dyspnea. Decreased work of breathing is not expected in this situation as COPD typically results in increased work of breathing.
4. A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?
- A. Take the medication in the morning.
- B. Increase potassium intake in the diet.
- C. Weigh yourself daily.
- D. Limit fluid intake to 2 liters per day.
Correct answer: C
Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.
5. What is the first priority for a patient in respiratory distress?
- A. Administer oxygen
- B. Assess airway patency
- C. Monitor oxygen saturation
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.
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