ATI LPN
ATI Comprehensive Predictor PN
1. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.
2. What are the side effects of chemotherapy, and how should they be managed?
- A. Nausea, vomiting; manage with antiemetics
- B. Hair loss and anemia; manage with blood transfusions
- C. Diarrhea and fatigue; manage with hydration
- D. Weight gain and high blood pressure; manage with diuretics
Correct answer: A
Rationale: The correct side effects of chemotherapy mentioned in this question are nausea and vomiting. These side effects are commonly managed with antiemetics to improve the quality of life for patients undergoing chemotherapy. Choice B (Hair loss and anemia) is incorrect as hair loss and anemia are potential side effects of chemotherapy but are not addressed in this question. Choice C (Diarrhea and fatigue) is also incorrect as it does not match the side effects provided. Choice D (Weight gain and high blood pressure) is inaccurate as these are not typical side effects of chemotherapy.
3. In an emergency mental health facility, a nurse is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?
- A. A client with schizophrenia who has delusions of grandeur
- B. A client with manifestations of depression who attempted suicide a year ago
- C. A client with borderline personality disorder who assaulted a homeless man with a metal rod
- D. A client with bipolar disorder who paces quickly around the room while talking to themselves
Correct answer: C
Rationale: The correct answer is C. A client with borderline personality disorder who has committed an assault poses a risk to others and themselves, necessitating temporary emergency admission for safety and further assessment. Choices A, B, and D do not indicate an immediate risk to self or others that would require temporary emergency admission.
4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Elevated blood glucose.
- B. Decreased urine output.
- C. Dependent edema.
- D. Jaundice.
Correct answer: C
Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.
5. A healthcare provider is planning care for a client who has a latex allergy. Which of the following actions should the healthcare provider include in the plan?
- A. Use latex gloves without powder.
- B. Place a sign on the client's door.
- C. Apply latex gloves before donning gloves.
- D. Avoid using latex equipment.
Correct answer: B
Rationale: Placing a sign on the client’s door is crucial in alerting healthcare providers to the client's latex allergy, helping them avoid using latex products, which can trigger an allergic reaction. This precaution can prevent accidental exposure and ensure the client's safety during care. Choices A, C, and D are incorrect. Using latex gloves without powder (Choice A) is a good practice, but the question is specifically asking about an action related to the client's latex allergy, not the healthcare provider's protection. Applying latex gloves before donning gloves (Choice C) is unnecessary and could exacerbate the client's latex allergy. Avoiding using plastic equipment (Choice D) is not related to preventing exposure to latex, which is the primary concern in this scenario.
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