ATI LPN
LPN Fundamentals of Nursing
1. A healthcare professional is preparing to perform nasotracheal suctioning for a client. Which of the following actions should the healthcare professional take?
- A. Suction during inhalation.
- B. Apply intermittent suction during insertion.
- C. Place the client in a supine position.
- D. Insert the catheter while the client is inhaling.
Correct answer: D
Rationale: Inserting the catheter while the client is inhaling helps to align the trachea and vocal cords, reducing the risk of trauma to the respiratory tract. This technique also facilitates easier passage of the catheter into the trachea, enhancing the effectiveness of the suctioning procedure.
2. When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
3. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
4. A client with meningitis is being assessed by a healthcare provider. Which of the following findings should the provider expect?
- A. Negative Brudzinski’s sign.
- B. Flaccid neck muscles.
- C. Petechial rash.
- D. Hypoactive deep tendon reflexes.
Correct answer: C
Rationale: A petechial rash is a characteristic finding in clients with meningitis, indicating small, pinpoint hemorrhages under the skin. This rash results from the infection's impact on the blood vessels. Petechiae are important to recognize as they can help differentiate meningitis from other conditions with similar symptoms. Brudzinski’s sign, neck stiffness, and positive Kernig’s sign are more common physical exam findings in meningitis. Flaccid neck muscles and hypoactive deep tendon reflexes are not typically associated with meningitis.
5. A client receives education on dietary management for ulcerative colitis from a nurse. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-fiber foods.
- B. You should avoid foods containing lactose.
- C. You should decrease your intake of dairy products.
- D. You should increase your intake of dairy products.
Correct answer: C
Rationale: The correct statement the nurse should include in the teaching is to decrease the intake of dairy products. This is because reducing the intake of dairy products is beneficial in managing symptoms of ulcerative colitis. Dairy products can aggravate symptoms due to their lactose content, thus advising the client to decrease their consumption can help alleviate discomfort and promote better management of the condition.\nChoice A is incorrect because increasing high-fiber foods may worsen symptoms in some individuals with ulcerative colitis.\nChoice B is incorrect as while it is advised to avoid foods containing lactose, this alone does not encompass the full dietary management for ulcerative colitis.\nChoice D is incorrect as increasing the intake of dairy products can exacerbate symptoms in individuals with ulcerative colitis due to their lactose content.
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