ATI LPN
PN ATI Comprehensive Predictor
1. A client post-surgery has a chest tube. What is the most important assessment for the nurse to perform?
- A. Clamp the chest tube for 30 minutes every 4 hours
- B. Check for air leaks and ensure the chest tube is functioning properly
- C. Position the client in a high Fowler's position
- D. Encourage frequent coughing to clear secretions
Correct answer: B
Rationale: The correct answer is to check for air leaks and ensure the chest tube is functioning properly. This is crucial post-surgery to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube, positioning the client, or encouraging coughing are not appropriate assessments for a client with a chest tube post-surgery and could lead to serious issues if done incorrectly.
2. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?
- A. Putting a glove on the dominant hand first
- B. Removing gloves and putting on a sterile gown first
- C. Putting sterile gloves last
- D. Applying gloves without touching outer surfaces
Correct answer: A
Rationale: The correct answer is A. Putting the glove on the dominant hand first is a key step in maintaining sterile technique as it reduces the risk of contamination. By covering the dominant hand first, the nurse minimizes the risk of contaminating the other hand during the glove application process. Choices B, C, and D are incorrect. Choice B introduces the concept of a sterile gown, which is not relevant to the question about applying sterile gloves. Choice C is incorrect as putting sterile gloves last does not follow the correct sequence of steps in maintaining sterility. Choice D, while important, is not as critical as covering the dominant hand first when applying sterile gloves.
3. A nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Tachycardia
- C. Hypotension
- D. Diaphoresis
Correct answer: A
Rationale: Corrected Rationale: Bradycardia is a common sign of hypoglycemia due to the body's response to low blood sugar. During hypoglycemia, the body releases epinephrine, leading to sympathetic nervous system activation. This can result in bradycardia as a compensatory mechanism to preserve glucose for vital organs such as the brain. Tachycardia, hypotension, and diaphoresis are more commonly associated with hypoglycemia when it progresses to severe stages and the body's compensatory mechanisms are overwhelmed.
4. A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?
- A. I can't brush my teeth properly
- B. I am so frustrated I can't open my milk carton
- C. I can't hold a pencil
- D. I can't write anymore
Correct answer: B
Rationale: The correct answer is B. The client's frustration with opening a milk carton indicates difficulty with activities of daily living, which is a common concern addressed by occupational therapists. Choices A, C, and D are related to fine motor skills, which may also be addressed by an occupational therapist but are not as directly linked to activities of daily living as struggling with tasks like opening containers.
5. What is the nurse's responsibility when caring for a client with a chest tube?
- A. Check for air leaks in the tubing every 4 hours
- B. Clamp the chest tube for 30 minutes every 4 hours
- C. Encourage deep breathing and coughing every 2 hours
- D. Keep the client in a high Fowler's position
Correct answer: A
Rationale: The correct answer is to check for air leaks in the tubing every 4 hours when caring for a client with a chest tube. This responsibility is crucial because it ensures proper chest tube function and helps prevent complications such as pneumothorax or hemothorax. Clamping the chest tube (Choice B) can lead to serious issues by causing a tension pneumothorax. Encouraging deep breathing and coughing (Choice C) is important for respiratory hygiene but is not directly related to chest tube care. Keeping the client in a high Fowler's position (Choice D) may be beneficial for some conditions but is not specific to chest tube management.
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