ATI LPN
LPN Fundamentals of Nursing
1. A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage pursed-lip breathing.
- B. Administer oxygen at 6 L/min via nasal cannula.
- C. Place the client in a supine position.
- D. Restrict fluid intake to less than 1,500 mL/day.
Correct answer: A
Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.
2. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?
- A. Fluid intake should double the urine output
- B. Fluid intake should be approximately equal to the urine output
- C. Fluid intake should be half the urine output
- D. Fluid intake should be inversely proportional to the urine output
Correct answer: B
Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.
3. The nurse overhears a physician yelling at a newly hired graduate nurse in the hall. What is the nurse's best caring response?
- A. Yell at the physician for yelling at a new graduate and report the incident to the supervisor.
- B. Wait until the situation ends and comfort the graduate privately.
- C. Suggest that the physician take a quieter and more private approach to the problem.
- D. Ignore the situation to avoid embarrassing the graduate further.
Correct answer: C
Rationale: Suggesting a quieter and more private approach to the problem is the best caring response as it addresses the issue respectfully. This response shows empathy towards the graduate nurse and also aims to improve the situation without escalating it further. Choice A is not ideal as responding to yelling with yelling can exacerbate the situation and create more tension. Choice B, while offering comfort, does not directly address the inappropriate behavior of the physician. Choice D is not recommended as ignoring the situation may not help the graduate nurse and can lead to the continuation of inappropriate behavior without intervention.
4. During a mental health assessment, a patient states, 'I just don't see the point in anything anymore.' This statement is an indication of which of the following?
- A. Anxiety disorder
- B. Bipolar disorder
- C. Depression
- D. Schizophrenia
Correct answer: C
Rationale: The patient's statement 'I just don't see the point in anything anymore' reflects feelings of hopelessness and a lack of purpose, which are common symptoms of depression. Depression is characterized by persistent feelings of sadness, emptiness, and loss of interest or pleasure in activities that were once enjoyable. While anxiety disorders can involve excessive worry and fear, bipolar disorder includes episodes of both depression and mania, and schizophrenia typically involves symptoms such as hallucinations and delusions. Therefore, depression is the most appropriate choice based on the patient's statement.
5. A nurse is teaching a client about the use of alendronate. Which of the following should be included in the teaching?
- A. Take it with food
- B. Sit upright for at least 30 minutes after taking it
- C. It can be taken at bedtime
- D. It is safe to take with antacids
Correct answer: B
Rationale: The correct answer is B: 'Sit upright for at least 30 minutes after taking it.' Alendronate can cause esophageal irritation and to reduce the risk of this side effect, clients should be instructed to sit upright for at least 30 minutes after administration. Choice A is incorrect as alendronate should be taken on an empty stomach, usually in the morning, at least 30 minutes before the first food, beverage, or medication of the day. Choice C is incorrect because alendronate should not be taken at bedtime, as the client should remain upright for at least 30 minutes after taking it. Choice D is incorrect as antacids can interfere with the absorption of alendronate, so they should not be taken together.
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