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. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?
- A. Administer humidified oxygen
- B. Restrict fluids
- C. Instruct the client to avoid the Valsalva maneuver
- D. Apply heat packs to the nose
Correct answer: C
Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.
3. What should be included in dietary teaching for a client with chronic kidney disease?
- A. Increase potassium-rich foods in the diet
- B. Limit potassium and phosphorus intake
- C. Increase intake of protein-rich foods
- D. Increase fluid intake to prevent dehydration
Correct answer: B
Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.
4. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?
- A. Apply heat packs to the area
- B. Use perfumed soap to cleanse the area
- C. Keep the area moist with lotion
- D. Avoid sun exposure to the treated area
Correct answer: D
Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.
5. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.
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