ATI LPN
ATI PN Adult Medical Surgical 2019
1. A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?
- A. Heart rate of 110 beats per minute.
- B. Blood pressure of 90/60 mm Hg.
- C. Urine output of 20 ml/hour.
- D. Dry mucous membranes.
Correct answer: C
Rationale: A urine output of 20 ml/hour indicates severe dehydration and impaired renal function. This finding suggests a critical state where the kidneys are conserving water, leading to reduced urine output. Immediate intervention is required to restore fluid balance and prevent further complications associated with severe dehydration. Choice A, a heart rate of 110 beats per minute, may indicate dehydration but is not as severe as the critically low urine output. Choice B, a blood pressure of 90/60 mm Hg, can be seen in dehydration but is not as concerning as the extremely low urine output. Choice D, dry mucous membranes, is a common sign of dehydration but does not require immediate intervention compared to the severely reduced urine output.
2. What are early indicators of dehydration?
- A. Dry mouth
- B. Increased thirst
- C. Decreased urine output
- D. Dizziness
Correct answer: A
Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.
3. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?
- A. The institution's restraints/seclusion policies
- B. The patient's competence
- C. The patient's voluntary/involuntary status
- D. The patient's nursing care plan
Correct answer: C
Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.
4. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?
- A. The client who has a fractured femur and reports sharp chest pain.
- B. The client who has a fever and is receiving antibiotics.
- C. The client who has a urinary tract infection and reports pain with urination.
- D. The client who is scheduled for surgery in the afternoon.
Correct answer: A
Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.
5. An elderly man has relied on one of his sons for his care. Now the son has become very involved with a religion other than the one in which he was raised. As a result, he now refuses to help his father. What can a nurse do to help in this family situation?
- A. Set up a family conference that includes the son
- B. Bring in help from other family members or outside
- C. Insist that the son help, along with other family members
- D. Ask the family's own spiritual adviser to intervene
Correct answer: A
Rationale: In this complex family situation, it is essential to approach the issue with sensitivity and understanding. Setting up a family conference that includes the son is the most appropriate action for the nurse to take. While it may seem challenging, there is a possibility that involving the son in a family discussion can help him understand the impact of his actions on his father and the rest of the family. By including him in the conversation, the son may realize the importance of his role in caring for his father. Insisting that the son help, along with other family members, could lead to resistance and further alienation. Asking the family's spiritual adviser to intervene may not be effective if the son is rebelling against the family's religion. If the family conference does not yield positive results, then bringing in help from other family members or an outside caregiver may become necessary to ensure the elderly man receives the care he needs.
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