ATI LPN
ATI Comprehensive Predictor PN
1. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?
- A. Use a bed exit alarm to notify staff of attempts to leave the bed
- B. Raise all four side rails for safety
- C. Encourage frequent ambulation with assistance
- D. Use restraints to prevent the client from getting out of bed
Correct answer: A
Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.
2. A client has a new prescription for nitroglycerin. Which of the following instructions should the nurse include?
- A. Store the medication in a cool, dry place.
- B. Take the medication as directed by the healthcare provider.
- C. Take the medication 30 minutes before meals.
- D. Take the medication at the first sign of chest pain.
Correct answer: D
Rationale: Instructing the client to take nitroglycerin at the first sign of chest pain is crucial for immediate relief of angina symptoms. Nitroglycerin is a fast-acting medication that helps dilate blood vessels, improving blood flow to the heart muscle. Therefore, prompt administration at the onset of chest pain is essential to alleviate anginal episodes effectively. Choices A, B, and C are incorrect because storing the medication properly, taking it as directed, or before meals are not specific instructions for managing acute anginal episodes, which require immediate action for symptom relief.
3. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?
- A. Allow the client to rest four to five times during the day
- B. Assess the cognitive functioning of the client regularly
- C. Provide reality orientation even if the memory loss is severe
- D. Maintain consistency in environment, routine, and caregivers
Correct answer: D
Rationale: The most relevant suggestion for minimizing stress in individuals with Alzheimer's disease is to maintain consistency in the environment, routine, and caregivers. This approach helps create a sense of familiarity and security for the individual, reducing stress and anxiety. Choice A is incorrect as it suggests allowing the client to go to bed multiple times during the day, which may disrupt their routine and lead to confusion. Choice B is incorrect as continuously testing cognitive functioning can be overwhelming and stressful for the individual. Choice C is also incorrect as providing reality orientation in cases of severe memory loss can cause frustration and confusion, ultimately increasing stress levels.
4. A healthcare provider is planning to administer medications to a client who is receiving enteral feedings through an NG tube. Which of the following actions should the healthcare provider plan to take?
- A. Dissolve each medication in 5 mL of sterile water.
- B. Administer medications through a secondary infusion.
- C. Mix medications with the enteral feeding.
- D. Flush the NG tube with 30 mL of water before and after administering medications.
Correct answer: D
Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings. Choices A, B, and C are incorrect. Dissolving medications in sterile water (Choice A) may not be suitable for all drugs, as some medications may require specific diluents. Administering medications through a secondary infusion (Choice B) is not the standard practice for enteral medication administration. Mixing medications with the enteral feeding (Choice C) can cause interactions between medications and the feeding formula, affecting their absorption and effectiveness.
5. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. In addition to administering high-flow oxygen, treatment should include:
- A. treating for shock and uterine massage during transport.
- B. uterine massage and transport.
- C. placing her on her left side and transport.
- D. internal vaginal pads and treating for shock during transport.
Correct answer: A
Rationale: In this scenario, the mother is showing signs of postpartum hemorrhage with increased heart rate, diaphoresis, and mild vaginal bleeding. The correct approach involves treating for shock by addressing hypovolemia and providing uterine massage to help control bleeding. Administering high-flow oxygen is essential. Therefore, the most appropriate option is to treat for shock and perform uterine massage during transport to manage the postpartum hemorrhage effectively.
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