ATI LPN
ATI PN Comprehensive Predictor 2020
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
- A. Administer scheduled doses of acetaminophen every 6 hr.
- B. Monitor the child's cardiac status.
- C. Administer antibiotics via intermittent IV bolus for 24 hr.
- D. Provide stimulation with children of the same age in the playroom.
Correct answer: B
Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.
2. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct answer: A
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.
3. Why might nurses not be the best choice to obtain informed consent from patients?
- A. Nurses may be tempted to influence the patient's decision in subtle ways.
- B. Nurses may not be able to answer some of the medical questions the patient asks.
- C. A signature obtained by anyone other than a physician will not stand up in court.
- D. Under the law, nurses are only allowed to act as witnesses to informed consent signatures.
Correct answer: B
Rationale: Nurses may not have the medical expertise to answer all the questions that patients may have regarding their treatment, which is a crucial aspect of obtaining informed consent. While nurses should not influence a patient's decision, it is not a major reason why they should not obtain informed consent. Signatures obtained by nurses are legally binding, and although nurses often act as witnesses, there is no legal restriction preventing them from obtaining informed consent itself.
4. What are the nursing interventions for a patient with COPD?
- A. Administer oxygen and provide breathing exercises
- B. Suction airway secretions and encourage coughing
- C. Administer bronchodilators and monitor oxygen saturation
- D. Restrict fluids and encourage mobility
Correct answer: A
Rationale: The correct answer is A: Administer oxygen and provide breathing exercises. These interventions are essential in managing COPD as they help improve lung function and oxygenation. Choice B is incorrect as suctioning airway secretions and encouraging coughing are not typically indicated for COPD patients. Choice C is incorrect as while administering bronchodilators is common in COPD treatment, monitoring oxygen saturation alone is not a comprehensive intervention. Choice D is incorrect as restricting fluids is not a standard intervention for COPD, and encouraging mobility, although beneficial, is not as directly related to managing COPD symptoms as administering oxygen and providing breathing exercises.
5. A patient with schizophrenia is prescribed risperidone. Which statement by the patient indicates understanding of the medication?
- A. I should take this medication at the same time every day.
- B. I can stop taking this medication once I feel better.
- C. I should avoid drinking alcohol while taking this medication.
- D. I should take this medication on an as-needed basis.
Correct answer: A
Rationale: The correct answer is A because taking the medication at the same time every day helps maintain consistent blood levels and effectiveness. Consistency in dosing is crucial for the medication to work optimally in managing symptoms of schizophrenia. Option B is incorrect because stopping the medication abruptly can lead to a worsening of symptoms. Option C is important as alcohol can interact with the medication and cause adverse effects. Option D is incorrect because risperidone is typically taken regularly, not on an as-needed basis, to manage symptoms effectively.
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