ATI LPN
ATI PN Comprehensive Predictor 2020
1. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: B
Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.
2. People with phenylketonuria should avoid foods made with which nonnutritive sweetener?
- A. acesulfame-K
- B. aspartame
- C. saccharin
- D. sucralose
Correct answer: B
Rationale: People with phenylketonuria should avoid aspartame because it contains phenylalanine, which they cannot metabolize. Acesulfame-K, saccharin, and sucralose do not contain phenylalanine and are safe for individuals with phenylketonuria. Therefore, the correct answer is B. Acesulfame-K, saccharin, and sucralose are incorrect choices because they do not pose a risk for individuals with phenylketonuria due to the absence of phenylalanine in their composition.
3. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?
- A. At the level of the umbilicus
- B. 1 cm above the symphysis pubis
- C. At the level of the xiphoid process
- D. 2 cm below the umbilicus
Correct answer: A
Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.
4. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
5. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer?
- A. 0.2 mL
- B. 0.5 mL
- C. 1.0 mL
- D. 1.5 mL
Correct answer: B
Rationale: To determine the volume of prochlorperazine to administer, divide the prescribed dose (2.5 mg) by the concentration of the medication (5 mg/mL). This calculation results in 0.5 mL. Therefore, the nurse should administer 0.5 mL to deliver the correct dose. Choice A (0.2 mL) is incorrect as it miscalculates the dosage. Choices C (1.0 mL) and D (1.5 mL) are also incorrect as they do not accurately reflect the calculated volume needed for the dose.
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