ATI LPN
LPN Fundamentals of Nursing
1. Prior to administering a blood transfusion, what should the healthcare professional do first?
- A. Prime the IV tubing with normal saline.
- B. Verify the client's identity.
- C. Obtain the blood product from the blood bank.
- D. Check the client's vital signs.
Correct answer: B
Rationale: Verifying the client's identity is the essential initial step before administering a blood transfusion. This action is crucial to confirm that the correct blood product is being administered to the right client, thereby preventing any potential errors or adverse reactions. Ensuring patient safety is paramount in healthcare, and verifying the client's identity is a fundamental safety measure that should always be prioritized.
2. A client with a new diagnosis of cirrhosis is receiving dietary management education from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of sodium-rich foods.
- B. You should decrease your intake of sodium-rich foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct answer: B
Rationale: Reducing the intake of sodium-rich foods is beneficial for managing fluid retention and symptoms of cirrhosis. Excessive sodium can lead to fluid buildup in the body, worsening edema and ascites commonly associated with cirrhosis. Therefore, advising the client to decrease their intake of sodium-rich foods is crucial in the dietary management of cirrhosis. Option A is incorrect as increasing sodium intake would exacerbate fluid retention. Option C is irrelevant to cirrhosis management unless the client has lactose intolerance. Option D is incorrect as increasing dairy product intake may not be suitable for all patients with cirrhosis, especially if they have complications like hepatic encephalopathy.
3. A nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take your pulse before taking the medication.
- B. Take the medication with an antacid.
- C. Double the dose if you miss one.
- D. Take the medication with a high-fiber meal.
Correct answer: A
Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.
4. A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?
- A. Selecting a 25-gauge needle
- B. Administering the injection at a 45° angle
- C. Using the ventrogluteal site for the injection
- D. Aspirating for blood return before injecting the medication
Correct answer: B
Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.
5. A client with cirrhosis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of sodium-rich foods.
- B. I should decrease my intake of sodium-rich foods.
- C. I should increase my intake of potassium-rich foods.
- D. I should decrease my intake of potassium-rich foods.
Correct answer: B
Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.
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