ATI LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?
- A. Medication history
- B. Fluid and electrolyte imbalances
- C. Psychosocial stressors
- D. Environmental factors
Correct answer: B
Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.
2. What is the MOST common cause of shock in infants and children?
- A. Severe allergic reaction
- B. Dehydration
- C. Accidental poisoning
- D. Cardiac failure
Correct answer: B
Rationale: Dehydration is the most common cause of shock in infants and children. In children, the body's fluid reserves are smaller compared to adults, making them more susceptible to dehydration, which can lead to shock if not promptly addressed. Severe allergic reactions, accidental poisoning, and cardiac failure can also cause shock, but dehydration is the most frequent cause in this age group.
3. A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?
- A. Dry cough.
- B. Weight gain.
- C. Tachycardia.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril is an ACE inhibitor, and a common side effect of ACE inhibitors is a dry cough. This occurs due to the accumulation of bradykinin in the lungs, leading to irritation and subsequent cough. It is important for the nurse to monitor the client for this side effect as it can affect adherence to the medication regimen. Weight gain, tachycardia, and hyperglycemia are not typically associated with lisinopril. Therefore, choices B, C, and D are incorrect.
4. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client's oxygen saturation level
- C. Provide standby assistance when getting out of bed
- D. Encourage foods high in potassium
Correct answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
5. A client with diabetes is being discharged. What is the most important teaching point?
- A. Monitor blood sugar levels once in the morning
- B. Administer insulin before meals as prescribed
- C. Take medication only when feeling unwell
- D. Monitor glucose levels weekly
Correct answer: B
Rationale: The most important teaching point for a client with diabetes being discharged is to administer insulin before meals as prescribed. This is crucial for managing blood sugar levels effectively and preventing complications. Monitoring blood sugar levels once in the morning (Choice A) is not sufficient for proper diabetes management, as levels can fluctuate throughout the day. Taking medication only when feeling unwell (Choice C) is not recommended as diabetes treatment is based on a regular schedule. Monitoring glucose levels weekly (Choice D) is not frequent enough to provide the necessary information for managing diabetes on a day-to-day basis.
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