ATI LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?
- A. Inject the medication into the muscle of the thigh
- B. Massage the injection site after administration
- C. Pinch the skin before injecting
- D. Administer the medication at the same time each day
Correct answer: C
Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.
2. What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?
- A. It must be a comfort to know you have another child.
- B. I'm sad for you.
- C. There is usually something wrong with the baby.
- D. You will always have an angel in heaven.
Correct answer: B
Rationale: Option B, 'I'm sad for you,' is the most appropriate response for the nurse to make to the client who has experienced a perinatal death. This statement conveys empathy and compassion, acknowledging the client's grief and validating their emotions. It opens the door for the client to express their feelings and facilitates further communication and support from the nurse. Choices A, C, and D are not appropriate in this context. Choice A may come across as dismissive of the client's grief by redirecting the focus to another child. Choice C suggests blame or fault, which is not helpful or accurate in most cases of perinatal death. Choice D, while well-intentioned, may not be comforting to all clients and could impose a specific belief system on the client's experience.
3. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?
- A. Assist the client to get back into bed.
- B. Report the chest pain episode to the healthcare provider.
- C. Tell the client to stand still and take the client's blood pressure.
- D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.
Correct answer: A
Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.
4. What is an important consideration when administering a blood transfusion?
- A. Ensure the blood is compatible with the recipient's blood type
- B. Warm the blood to body temperature before administration
- C. Check the blood for clots before administration
- D. Ensure the recipient eats before the transfusion
Correct answer: A
Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.
5. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct answer: B
Rationale: The priority action for the nurse in this situation is to position the client with one hip elevated. This position can help improve blood flow to the placenta and stabilize blood pressure, which is crucial for both the client and the fetus during labor. It can also help optimize fetal oxygenation by improving circulation. Notifying the provider of the findings may be necessary, but ensuring proper positioning of the client takes precedence to address the immediate physiological needs. Asking the client about pain medication or having the client void are important interventions but are not the priority in this scenario where the client is experiencing painful contractions and has low blood pressure.
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