ATI LPN
ATI PN Comprehensive Predictor 2020
1. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?
- A. Administer pain medication
- B. Perform a fundal massage
- C. Check the baby's heart rate
- D. Apply an ice pack
Correct answer: B
Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.
2. 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.
3. A healthcare provider is preparing to administer a dose of clindamycin. Which of the following should the provider assess first?
- A. Allergy history
- B. Vital signs
- C. Renal function
- D. Liver function
Correct answer: A
Rationale: When preparing to administer clindamycin, assessing the patient's allergy history is crucial as clindamycin can cause severe allergic reactions. This assessment helps identify any potential risks related to allergies and enables the healthcare provider to take necessary precautions. Vital signs, renal function, and liver function are also important assessments before administering medications, but in this case, checking for any history of allergies takes priority due to the risk of severe allergic reactions associated with clindamycin.
4. In family nursing, the typology of family nursing problems is used in the statement of nursing diagnosis for families. The youngest child of the Delos Reyes family has been diagnosed with mental retardation. This is classified as:
- A. Health threat
- B. Health deficit
- C. Foreseeable crisis
- D. Stress point
Correct answer: B
Rationale: In the context of family nursing, when a family member like the youngest child is diagnosed with mental retardation, it represents a health deficit. A health deficit occurs when a family member fails to develop as expected, as in the case of mental retardation. This classification helps nurses identify and address the specific health needs of the family.
5. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?
- A. Instruct the client to remain in bed until the fatigue resolves
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to perform all self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct answer: B
Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.
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