ATI LPN
ATI PN Comprehensive Predictor
1. A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?
- A. Haloperidol
- B. Zolpidem
- C. Morphine
- D. Lorazepam
Correct answer: B
Rationale: The correct answer is B: Zolpidem. Zolpidem is a sedative-hypnotic medication that can worsen altered mental status, especially in clients who are already aggressive. Therefore, the nurse should clarify this prescription with the provider before administration to ensure it is safe for the client. Choice A, Haloperidol, is an antipsychotic commonly used to manage aggression in clients with altered mental status, making it an appropriate choice in this scenario. Choice C, Morphine, is an opioid analgesic and would not directly impact the client's altered mental status or aggression. Choice D, Lorazepam, is a benzodiazepine used to manage anxiety and agitation, which could be beneficial in this situation but does not have the same potential to exacerbate altered mental status as Zolpidem.
2. What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?
- A. Notify the provider
- B. Suction the tracheostomy
- C. Administer a bronchodilator
- D. Increase the oxygen flow rate
Correct answer: B
Rationale: The correct initial action when a client with a tracheostomy exhibits respiratory distress is to suction the tracheostomy. This helps to clear secretions and improve the client's ability to breathe. Notifying the provider (choice A) can cause a delay in immediate intervention. Administering a bronchodilator (choice C) may be necessary but is not the priority in this situation. Increasing the oxygen flow rate (choice D) can be helpful but should come after addressing the immediate need for suctioning to clear the airway.
3. What are the signs of hypoglycemia, and how should they be managed?
- A. Sweating, trembling; administer glucose
- B. Headache, confusion; administer insulin
- C. Dizziness, fatigue; administer glucose
- D. Increased heart rate; provide a high-sugar snack
Correct answer: A
Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.
4. What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.
5. A client who is postpartum is being taught about breast care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wear tight-fitting bras to reduce discomfort
- B. I will nurse my baby frequently to prevent engorgement
- C. I will pump my breasts every 4 hours
- D. I will avoid nursing for at least 48 hours
Correct answer: B
Rationale: The correct answer is B. Nursing the baby frequently helps prevent engorgement and discomfort in breastfeeding mothers. Choice A is incorrect because tight-fitting bras can lead to clogged milk ducts and worsen discomfort. Choice C may lead to oversupply issues and is not necessary unless there is a specific indication. Choice D is incorrect as avoiding nursing for extended periods can lead to engorgement and decreased milk supply.
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