ATI LPN
LPN Fundamentals of Nursing
1. When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?
- A. Wear sterile gloves to remove the old dressing.
- B. Cleanse the wound with an antiseptic solution.
- C. Use clean gloves to apply the new dressing.
- D. Open sterile supplies before donning sterile gloves.
Correct answer: D
Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.
2. A nurse is assessing a client who has been taking lithium carbonate. Which of the following findings should the nurse report to the provider?
- A. Increased urination
- B. Tremors
- C. Weight gain
- D. Blurred vision
Correct answer: B
Rationale: The correct answer is B: Tremors. Tremors are a sign of lithium toxicity and should be reported immediately. Increased urination is a common side effect of lithium but not an urgent concern requiring immediate reporting. Weight gain is also a common side effect of lithium but does not indicate toxicity. Blurred vision is not typically associated with lithium toxicity; therefore, it is not the priority finding to report.
3. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.
4. What theme of critical thinking is demonstrated by the belief that continuous learning contributes to the ongoing process?
- A. Critical thinking is a productive and positive activity.
- B. Critical thinking is a process, not an outcome.
- C. Manifestations of critical thinking vary, depending on the context in which they occur.
- D. Critical thinking is triggered by both positive and negative events.
Correct answer: B
Rationale: The belief that continuous learning contributes to the ongoing process aligns with the theme that critical thinking is a process, not an outcome. This suggests that critical thinking involves a continuous, dynamic process of evaluating information, making connections, and adapting one's thinking over time, rather than being a fixed end result. Therefore, choice B is the correct answer. Choices A, C, and D do not directly address the continuous nature of critical thinking or its ongoing development, making them incorrect.
5. A patient with obsessive-compulsive disorder (OCD) spends hours washing their hands. Which nursing intervention is most appropriate?
- A. Encouraging the patient to stop washing their hands
- B. Allowing the patient to wash hands at specified times
- C. Ignoring the patient's behavior
- D. Setting strict limits on the time allowed for hand washing
Correct answer: B
Rationale: In managing a patient with OCD who spends excessive time washing hands, allowing the patient to wash hands at specified times is the most appropriate nursing intervention. This approach helps establish a structured routine for hand washing, which can assist in managing OCD symptoms without reinforcing the behavior. Encouraging the patient to stop washing hands may lead to increased anxiety and resistance. Ignoring the behavior can perpetuate the cycle of OCD, and setting strict limits on hand washing time may cause distress and may not effectively address the underlying issues associated with OCD.
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