ATI LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?
- A. Encourage ambulation
- B. Apply ice packs
- C. Restrict the client's fluid intake
- D. Administer stool softeners
Correct answer: B
Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.
2. A client with schizophrenia taking clozapine is being assessed by a nurse. Which of the following findings is the priority for the nurse to report to the provider?
- A. Elevated blood pressure
- B. Fever
- C. Weight gain
- D. Dry mouth
Correct answer: B
Rationale: The priority finding for the nurse to report to the provider is B: Fever. Fever can be an indication of agranulocytosis, a potentially life-threatening condition associated with clozapine. Agranulocytosis is characterized by a significant decrease in white blood cells, making the client susceptible to severe infections. Prompt reporting of fever is crucial to prevent serious complications. Elevated blood pressure (Choice A), weight gain (Choice C), and dry mouth (Choice D) are important to monitor but are not as immediately concerning as fever, which could indicate a severe adverse reaction requiring urgent medical attention.
3. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion
- B. Apply oxygen at 2 L/min via nasal cannula
- C. Prepare for insertion of an intrauterine pressure catheter
- D. Assist the client into the knee-chest position
Correct answer: D
Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.
4. What should a healthcare professional prioritize when managing a client with delirium?
- A. Administering sedative medication
- B. Providing a low-stimulation environment
- C. Identifying the underlying cause of the delirium
- D. Controlling behavioral symptoms with medication
Correct answer: C
Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.
5. A healthcare professional walks into the nurse's station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the healthcare professional take first?
- A. remind the staff members that this is a breach of confidentiality
- B. discuss the issue with the unit manager
- C. request that an administrative restriction be placed on the client's medical access
- D. prepare a report for the facility ethics committee
Correct answer: A
Rationale: The correct action for the healthcare professional to take first is to remind the staff members that accessing the electronic medical record of a celebrity client from another unit is a breach of confidentiality. This immediate action addresses the ethical and legal issue at hand, emphasizing the importance of patient confidentiality and privacy. Discussing the issue with the unit manager, requesting administrative restrictions, or preparing a report for the facility ethics committee can be considered after addressing the initial breach and reminding staff members of their obligations.
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