ATI LPN
ATI NCLEX PN Predictor Test
1. How should a healthcare professional assess and manage a patient with delirium?
- A. Assess for confusion and reorient the patient
- B. Provide a quiet environment and administer sedatives
- C. Provide oxygen therapy and monitor vital signs
- D. Provide pain relief and monitor for signs of recovery
Correct answer: A
Rationale: The correct way to assess and manage a patient with delirium is by assessing for confusion and reorienting the patient. Delirium is characterized by acute confusion and disturbance in attention, so reorienting the patient to time, place, and person can help improve their awareness and cognition. Providing a quiet environment is important to reduce stimuli that can exacerbate delirium, but administering sedatives may worsen the condition. Oxygen therapy and monitoring vital signs are essential aspects of general patient care but are not specific to managing delirium. Providing pain relief is important for overall patient comfort but may not directly address the core issue of delirium.
2. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?
- A. Use the cane on the weaker side
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm with each step
Correct answer: C
Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.
3. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?
- A. Hypertension
- B. Vomiting
- C. Drainage from the ear
- D. Unequal pupils
Correct answer: D
Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.
4. A nurse is caring for a client who has been diagnosed with hyperkalemia. Which of the following findings should the nurse expect?
- A. Muscle weakness
- B. Nausea
- C. Increased thirst
- D. Restlessness
Correct answer: A
Rationale: Muscle weakness is a characteristic finding in hyperkalemia. High levels of potassium can affect the normal function of muscles, leading to weakness. Nausea and increased thirst are not typically associated with hyperkalemia. Restlessness is more commonly seen in conditions such as hypoxia or anxiety, not specifically in hyperkalemia.
5. A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?
- A. Maintain the client in the lithotomy position.
- B. Perform vaginal examinations frequently.
- C. Remind the client to bear down with each contraction.
- D. Encourage the client to empty her bladder every 2 hours.
Correct answer: D
Rationale: Encouraging the client to empty her bladder every 2 hours is essential during labor to prevent bladder distention, which can hinder labor progress and cause discomfort. A distended bladder can also lead to potential complications such as uterine atony or increased risk of infection. Choice A is incorrect as maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor and may not be comfortable for the client. Choice B is incorrect because performing vaginal examinations frequently can increase the risk of introducing infection and disrupt the natural progress of labor. Choice C is incorrect as bearing down with each contraction is typically reserved for the second stage of labor when the cervix is fully dilated, not during the active phase of the first stage.
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