ATI LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraints to a non-moving part of the bed.
- C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
- D. Remove the client's restraints based on the client's condition.
Correct answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.
2. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:
- A. Allow the child to inspect the equipment for faults before and during assessment
- B. Ask parent to leave room until assessment has been completed
- C. Perform traumatic or invasive procedures first
- D. Have the child sit in parents lap and request assistance if necessary
Correct answer: D
Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.
3. A healthcare provider is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the healthcare provider plan to administer?
- A. Lidocaine
- B. Adenosine
- C. Atropine
- D. Verapamil
Correct answer: C
Rationale: The client presents with bradycardia, diaphoresis, and chest pain, indicating reduced cardiac output. Atropine is the appropriate choice as it increases heart rate by blocking the parasympathetic nervous system. Lidocaine is used for ventricular arrhythmias, Adenosine for supraventricular tachycardia, and Verapamil for controlling heart rate in atrial fibrillation or atrial flutter. These medications are not suitable for the client's current presentation.
4. How should a healthcare professional assess and manage a patient with a tracheostomy?
- A. Monitor for signs of infection and ensure airway patency
- B. Suction airway secretions and provide humidified air
- C. Inspect stoma site and clean with saline
- D. Provide education on tracheostomy care
Correct answer: A
Rationale: Correct answer: Monitoring for signs of infection and ensuring airway patency is crucial in managing a patient with a tracheostomy. This involves observing for redness, swelling, or discharge at the stoma site, as well as assessing for any signs of respiratory distress. Choice B, suctioning airway secretions and providing humidified air, is important for maintaining airway hygiene but may not be the initial assessment priority. Choice C, inspecting the stoma site and cleaning with saline, is part of routine tracheostomy care but does not address immediate assessment and management needs. Choice D, providing education on tracheostomy care, is valuable but not the primary action required in the assessment and management of a patient with a tracheostomy.
5. A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
- A. Administer oxygen via face mask.
- B. Notify the operating room team.
- C. Place the client in Trendelenburg.
- D. Administer a fluid bolus of 500 ml.
Correct answer: C
Rationale: In this scenario, the priority action for the nurse is to place the client in Trendelenburg position. This position helps alleviate pressure on the umbilical cord, preventing compression and ensuring continued blood flow to the fetus. Administering oxygen, notifying the operating room team, or administering a fluid bolus are not the initial priority actions in a cord prolapse situation.
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