ATI LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?
- A. Apply a cold compress to the site
- B. Notify the provider immediately
- C. Remove the IV catheter and restart it in another location
- D. Monitor the site for signs of infection
Correct answer: C
Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.
2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client’s skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder frequently to the client’s skin under the vest to decrease itching
Correct answer: B
Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.
3. When responding to a call for a 2-year-old child who fell from a second-story window, with the mechanism of injury and the age of the patient in mind, you should suspect that the primary injury occurred to the child's:
- A. chest.
- B. head.
- C. lower extremities.
- D. abdomen.
Correct answer: B
Rationale: In a scenario where a young child falls from a significant height like a second-story window, the primary injury is more likely to be to the head. This is because young children have proportionately larger head sizes compared to their body, making them more susceptible to head injuries in such falls. The chest (Choice A), lower extremities (Choice C), and abdomen (Choice D) are less likely to sustain the primary injury in this scenario, as the impact of the fall and the child's anatomy predispose the head to be the most affected area.
4. A client undergoing bariatric surgery is being taught about postoperative dietary changes by a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will drink carbonated beverages after surgery
- B. I will eat large meals after surgery
- C. I will avoid consuming solid foods for several weeks
- D. I will avoid taking small sips of liquids
Correct answer: C
Rationale: The correct answer is C because avoiding solid foods after bariatric surgery is crucial to prevent complications and promote healing. Choice A is incorrect as carbonated beverages can cause discomfort and should be avoided. Choice B is incorrect as large meals are not suitable after bariatric surgery. Choice D is incorrect as taking small sips of liquids is encouraged to prevent dehydration and promote recovery.
5. A client with severe preeclampsia is receiving magnesium sulfate intravenously. Which action should the nurse take when toxicity occurs?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: When toxicity from magnesium sulfate occurs, the nurse should administer calcium gluconate IV as it is the antidote for magnesium sulfate toxicity. Positioning the client supine may not address the toxicity issue. Administering dextrose 5% is not the appropriate intervention for magnesium sulfate toxicity. Methylergonovine is used to manage postpartum hemorrhage and is not indicated for magnesium sulfate toxicity.
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