ATI LPN
LPN Fundamentals of Nursing
1. What action should a healthcare provider take for a client with a new colostomy?
- A. Empty the colostomy bag when it is half full.
- B. Place aspirin in the colostomy bag to decrease odor.
- C. Use sterile technique when caring for the stoma.
- D. Change the pouch every 8 hours.
Correct answer: A
Rationale: Emptying the colostomy bag when it is half full is crucial to prevent leakage and detachment from the skin. This practice helps to maintain the integrity of the colostomy system, reducing the risk of skin irritation and odor. It is essential for client comfort and overall stoma care.
2. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?
- A. Apply a heat lamp to the area for 20 minutes each day.
- B. Change the dressing on the heel every 12 hours.
- C. Apply a transparent dressing over the heel.
- D. Use a water pressure mattress.
Correct answer: C
Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.
3. During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?
- A. Avoid lying on your operative side.
- B. Cross your legs at the ankles only.
- C. Place a pillow between your legs when turning.
- D. Avoid bending your hip more than 120 degrees.
Correct answer: C
Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.
4. A nurse is caring for a client who has a new prescription for a low-cholesterol diet. Which of the following foods should the nurse recommend?
- A. Eggs
- B. Cheese
- C. Chicken breast
- D. Butter
Correct answer: C
Rationale: Chicken breast is a suitable recommendation for a low-cholesterol diet as it is low in cholesterol. Eggs and cheese are high in cholesterol and not suitable for a low-cholesterol diet. Butter is also high in cholesterol and should be avoided in a low-cholesterol diet.
5. What action is required by law when preparing to administer a controlled substance?
- A. Verify the client’s identification using two identifiers.
- B. Document the medication administration in the client’s chart immediately.
- C. Return any unused portion of the medication to the pharmacy.
- D. Have a second nurse witness the disposal of any unused portion.
Correct answer: D
Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.
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