ATI LPN
LPN Fundamentals of Nursing
1. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?
- A. Massage the reddened area.
- B. Apply a donut-shaped cushion.
- C. Reposition the client every 3 hours.
- D. Use a transparent film dressing.
Correct answer: D
Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.
2. What is the MOST common cause of shock in infants and children?
- A. Severe allergic reaction
- B. Dehydration
- C. Accidental poisoning
- D. Cardiac failure
Correct answer: B
Rationale: Dehydration is the most common cause of shock in infants and children. In children, the body's fluid reserves are smaller compared to adults, making them more susceptible to dehydration, which can lead to shock if not promptly addressed. Severe allergic reactions, accidental poisoning, and cardiac failure can also cause shock, but dehydration is the most frequent cause in this age group.
3. A nurse is assessing a client who is taking amiodarone. Which of the following findings should the nurse report to the provider?
- A. Dry skin
- B. Weight loss
- C. Bradycardia
- D. Productive cough
Correct answer: D
Rationale: A productive cough can indicate pulmonary toxicity, a serious side effect of amiodarone, and should be reported. Dry skin is not typically associated with amiodarone use. Weight loss is a common side effect of amiodarone but not generally a cause for concern unless severe. Bradycardia is a known side effect of amiodarone and may not necessarily require immediate reporting unless symptomatic.
4. Which nursing intervention is essential for a client diagnosed with heart failure?
- A. Encourage fluid intake to prevent dehydration
- B. Monitor the client's weight daily to assess fluid balance
- C. Increase sodium intake to prevent fluid retention
- D. Limit fluid intake to avoid overload
Correct answer: B
Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.
5. A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct answer: A
Rationale: The correct response is A: 'The cancer involves only the cervix.' In staging, 'Tis' indicates cancer in situ, which means it is localized to the cervix and not invasive at this time. The differentiation of cancer cells is not part of clinical staging. Since the cancer is in situ, its origin is the cervix. Further testing is not required as the cancer has not spread beyond the cervix. Choice B is incorrect as the staging information provided does not relate to the resemblance of cancer cells to normal cells. Choice C is incorrect because further testing is not necessary as the cancer is localized. Choice D is incorrect because the staging information provided clearly indicates the site of origin as the cervix.
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