ATI LPN
ATI PN Comprehensive Predictor 2024
1. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?
- A. Cross your legs at the knees
- B. Avoid bending your hip more than 90 degrees
- C. Sit with your legs elevated
- D. Avoid placing a pillow under your knees
Correct answer: B
Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.
2. What are the steps in managing a patient with a pressure ulcer?
- A. Clean the wound and apply a hydrocolloid dressing
- B. Debride necrotic tissue and apply antibiotics
- C. Apply an alginate dressing and elevate the affected area
- D. Use moisture-retentive dressings and reposition frequently
Correct answer: A
Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.
3. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?
- A. Decerebrate posturing.
- B. Hypervigilance.
- C. Absence of deep tendon reflexes.
- D. Glasgow Coma Scale score of 15.
Correct answer: A
Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.
4. What are the primary causes of respiratory acidosis?
- A. Hypoventilation and lung disease
- B. Hyperventilation and pneumonia
- C. Increased oxygen saturation and tachypnea
- D. Dehydration and hypoxia
Correct answer: A
Rationale: The correct answer is A: Hypoventilation and lung disease. Respiratory acidosis occurs when there is an accumulation of CO2 in the body due to inadequate ventilation. Hypoventilation, which reduces the elimination of CO2, and lung diseases that impair gas exchange are the primary causes. Choice B is incorrect because hyperventilation, not hypoventilation, leads to respiratory alkalosis, not acidosis. Choice C is incorrect because increased oxygen saturation and tachypnea do not directly cause respiratory acidosis. Choice D is incorrect as dehydration and hypoxia do not typically lead to respiratory acidosis.
5. What are the key components of a neurological assessment?
- A. Assess level of consciousness and motor function
- B. Check for headache and nausea
- C. Monitor reflexes and pupil size
- D. Assess for tremors and confusion
Correct answer: A
Rationale: The correct answer is A. A neurological assessment includes evaluating the level of consciousness and motor function as they are key components in assessing neurological function. Choices B, C, and D are incorrect as headache, nausea, reflexes, pupil size, tremors, and confusion may be part of a neurological assessment but are not the key components that are fundamental for a comprehensive assessment.
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