ATI LPN
LPN Fundamentals of Nursing
1. When teaching a client how to perform self-catheterization, which of the following instructions should be included?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter with alcohol after each use.
- C. Insert the catheter 2-4 inches into the urethra.
- D. Perform the procedure every 8 hours.
Correct answer: C
Rationale: To ensure effective drainage, the catheter should be inserted 2-4 inches into the urethra. This length allows the catheter to reach the bladder, bypass the urethral sphincters, and ensure proper drainage without causing discomfort or injury. Using sterile gloves, cleaning the catheter with alcohol, and performing the procedure every 8 hours are not accurate instructions for self-catheterization.
2. A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?
- A. I should increase my intake of dairy products.
- B. I should decrease my intake of dairy products.
- C. I should increase my intake of high-fiber foods.
- D. I should decrease my intake of high-fat foods.
Correct answer: B
Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.
3. During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?
- A. Apply palms of both hands to sides of the uterus
- B. Palpate the fundus of the uterus
- C. Grasp the lower uterine segment between thumb and fingers
- D. Stand facing the client's feet with fingertips outlining cephalic prominence
Correct answer: B
Rationale: Palpating the fundus of the uterus during Leopold maneuvers is crucial to identify the fetal lie. This technique allows the nurse to determine the position of the baby's back and locate the fetal heart sounds, aiding in assessing the fetal lie. Choices A, C, and D are incorrect as they do not directly relate to identifying the fetal lie during Leopold maneuvers. Applying palms to the sides of the uterus or grasping the lower uterine segment do not provide the necessary information about the fetal lie. Standing facing the client's feet and outlining cephalic prominence is more related to assessing the fetal presentation, not the fetal lie.
4. A nurse is planning a staff education program to review nursing interventions for patients who have kidney failure. What source should the nurse identify as the best source for obtaining evidence-based practice information?
- A. A recent peer-reviewed nursing research article
- B. A website for a nursing association
- C. A textbook published 5 years ago
- D. An expert opinion from a seasoned nurse
Correct answer: A
Rationale: The correct answer is A: A recent peer-reviewed nursing research article. Peer-reviewed research articles provide the most current and reliable evidence-based practice information for clinical care. Choice B, a website for a nursing association, may have valuable information but may not always guarantee the highest level of evidence. Choice C, a textbook published 5 years ago, may not reflect the most up-to-date practices and guidelines. Choice D, an expert opinion from a seasoned nurse, though valuable, is not as reliable as evidence derived from peer-reviewed research articles.
5. When a client states, 'My water just broke,' what is the nurse's priority intervention?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct answer: D
Rationale: The correct answer is D: Begin FHR monitoring. The priority intervention when a client's water breaks is to assess the fetal well-being due to the risk of umbilical cord prolapse. Monitoring the fetal heart rate (FHR) will help the nurse ensure the fetus's well-being. Performing Nitrazine testing (choice A) or assessing the fluid (choice B) may provide information about the rupture of membranes but does not directly address fetal well-being. Checking cervical dilation (choice C) is important but not the priority when the client's water has broken.
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