ATI LPN
ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?
- A. Avoid taking blood pressures on the arm with the AV fistula.
- B. Check the fistula site daily for pallor.
- C. Place a warm compress over the fistula site every 4 hours.
- D. Keep the client's arm elevated on two pillows.
Correct answer: A
Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.
2. The healthcare provider is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The provider should place the highest priority on making sure that which is available at the bedside?
- A. Bedside commode
- B. Rolling shower chair
- C. Oxygen tubing and flowmeter
- D. Twelve-lead electrocardiogram (ECG) machine
Correct answer: C
Rationale: In a client with coronary artery disease (CAD), ensuring the availability of oxygen and a flowmeter at the bedside is crucial. Oxygen is essential for adequate oxygenation, which helps prevent myocardial ischemia, a common complication in CAD. The other options, such as a bedside commode and rolling shower chair, are important for patient comfort and mobility but are not as critical as ensuring proper oxygen supply in a client with CAD. While having an ECG machine available is important for ongoing monitoring, ensuring oxygen availability takes precedence in this scenario.
3. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?
- A. I will make sure my medications are enteric-coated.
- B. My stoma will drain liquid continuously.
- C. I will change my pouch system every two weeks.
- D. My stoma size will stay the same after it heals.
Correct answer: B
Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.
4. Which statistic can provide the most accurate reflection of the health status of a community?
- A. 1-4 year old age-specific mortality rate
- B. Infant mortality rate
- C. Swaroop’s index
- D. Crude death rate
Correct answer: C
Rationale: Swaroop’s index is a valuable statistic that reflects the health status of a community by indicating the proportion of deaths aged 50 years and above. A higher Swaroop’s index signifies a greater proportion of individuals who lived at least 50 years before passing away. This metric provides insight into the overall health and longevity of a population, making it a more accurate reflection of community health compared to other mortality rates.
5. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?
- A. Inject the medication into the muscle of the thigh
- B. Massage the injection site after administration
- C. Pinch the skin before injecting
- D. Administer the medication at the same time each day
Correct answer: C
Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.
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