ATI LPN
ATI PN Comprehensive Predictor 2020
1. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?
- A. Wear sterile gloves when applying a new dressing
- B. Cleanse the wound from the center outwards
- C. Keep the wound dry between dressing changes
- D. Apply an antimicrobial ointment to the wound
Correct answer: B
Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.
2. A client receiving IV fluids has developed phlebitis. What action should the nurse take next after removing the IV catheter?
- A. Place a warm compress over the IV site
- B. Record the findings in the client's chart
- C. Notify the client's primary care provider
- D. Insert a new IV catheter
Correct answer: A
Rationale: After removing an IV catheter due to phlebitis, the next step is to apply a warm compress over the IV site. This helps reduce inflammation and discomfort for the client. Recording the findings in the client's chart is important for documentation purposes but not the immediate next step. Notifying the client's primary care provider may be necessary depending on the severity of the phlebitis, but it is not the initial action. Inserting a new IV catheter is not appropriate until the phlebitis has resolved.
3. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?
- A. Administer humidified oxygen
- B. Restrict fluids
- C. Instruct the client to avoid the Valsalva maneuver
- D. Apply heat packs to the nose
Correct answer: C
Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.
4. What should be done to minimize the risk of injury for a client with dementia?
- A. Ensure the client has consistent caregivers
- B. Dim the lights in the client's room
- C. Allow the client to sleep with the bedrails raised
- D. Encourage family members to stay with the client
Correct answer: A
Rationale: The correct answer is to ensure the client has consistent caregivers. This helps reduce confusion and stress for clients with dementia by providing familiarity and routine. Dimming the lights in the client's room (Choice B) may not directly address the risk of injury. Allowing the client to sleep with the bedrails raised (Choice C) can pose a risk if not properly monitored. Encouraging family members to stay with the client (Choice D) may not always be feasible and may not provide the necessary professional support and consistency that consistent caregivers can offer.
5. A client has a prescription for ciprofloxacin. Which of the following instructions should the nurse include?
- A. Take the medication with an antacid if you experience gastrointestinal upset.
- B. You should limit your caffeine intake while taking this medication.
- C. This medication may cause your urine to turn dark brown.
- D. You should avoid taking this medication with dairy products.
Correct answer: D
Rationale: The correct answer is D: 'You should avoid taking this medication with dairy products.' Ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice A is incorrect because ciprofloxacin should not be taken with antacids containing aluminum or magnesium. Choice B is incorrect as there is no specific limitation on caffeine intake associated with ciprofloxacin. Choice C is incorrect as ciprofloxacin does not typically cause urine to turn dark brown.
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