ATI LPN
LPN Fundamentals of Nursing
1. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
2. A client is discussing free associations as a therapeutic tool with a nurse. Which of the following client statements indicates an understanding of this technique?
- A. “I will write down my dreams as soon as I wake up.”
- B. “I might begin to associate my therapist with important people in my life.”
- C. “I can learn to express myself in a nonaggressive manner.”
- D. “I should say the first thing that comes to my mind.”
Correct answer: D
Rationale: Free association is a psychoanalytic technique where the client is encouraged to say the first thing that comes to their mind without censoring or filtering. This technique helps uncover unconscious thoughts and emotions. Choice D, “I should say the first thing that comes to my mind,” indicates an understanding of free association as it aligns with the principle of allowing thoughts to flow freely without inhibition. Choices A, B, and C do not reflect an understanding of free association and its purpose, making them incorrect. A, focusing on writing down dreams, does not relate to the immediate expression of thoughts. B, associating the therapist with important people, and C, learning to express oneself nonaggressively, do not capture the essence of free association as a technique for exploring unconscious processes.
3. A nurse is reviewing the ABG results of a client with chronic emphysema. Which result suggests the need for further treatment?
- A. PaO2 level of 89 mm Hg
- B. PaCO2 level of 55 mm Hg
- C. HCO3 level of 25 mEq/L
- D. pH level of 7.37
Correct answer: B
Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.
4. The healthcare provider has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?
- A. I should substitute eggs and milk for meat.
- B. I will eliminate all cholesterol and fat from my diet.
- C. I should routinely use polyunsaturated oils in my diet.
- D. I need to consider becoming a strict vegetarian.
Correct answer: C
Rationale: The correct answer is C. Using polyunsaturated oils, such as vegetable oils, can help manage cholesterol levels and reduce the risk of heart disease. This dietary change is beneficial for individuals with coronary artery disease as it promotes heart health by improving cholesterol profiles. Substituting eggs and milk for meat (Choice A) may not address the overall dietary needs for managing the condition. Completely eliminating all cholesterol and fat from the diet (Choice B) is not necessary as the body needs some healthy fats. Considering becoming a strict vegetarian (Choice D) is a personal choice and may not necessarily be required to manage coronary artery disease.
5. A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching?
- A. “Your provider will use stool samples from your bowel movement to perform the test.”
- B. “Your provider will prescribe a stimulant laxative prior to the procedure to cleanse the bowel.”
- C. “You should begin biennial fecal occult blood testing for colorectal cancer screening at 50 years old.”
- D. “You should avoid taking corticosteroids prior to testing.”
Correct answer: D
Rationale: The correct answer is D. The nurse should instruct the client to avoid corticosteroids and vitamin C prior to testing to prevent false-positive results. Choice A is incorrect because stool samples from bowel movements, not from digital rectal examinations, are used for FOBT. Choice B is incorrect because a stimulant laxative is not typically prescribed before FOBT; rather, the client is instructed to follow specific dietary restrictions. Choice C is incorrect because biennial fecal occult blood testing for colorectal cancer screening usually begins at 50 years old, not 40.
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