ATI LPN
Pediatric ATI Proctored Test
1. The healthcare provider assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. Based on this finding, which action is most appropriate?
- A. Administer oxygen
- B. Document the findings
- C. Notify the healthcare provider
- D. Reassess the respiratory rate in 15 minutes
Correct answer: B
Rationale: Documenting the findings is the most appropriate action since a respiratory rate of 35 breaths per minute falls within the normal range for a 12-month-old infant. There is no immediate need for interventions such as administering oxygen or notifying the healthcare provider. Reassessing the respiratory rate in 15 minutes is unnecessary as the rate is within normal limits.
2. When teaching a client who has a new prescription for metformin, which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Monitor for signs of hyperglycemia.
- C. Increase your fluid intake.
- D. Expect a metallic taste in your mouth.
Correct answer: C
Rationale: The correct instruction for a client starting metformin is to increase fluid intake. This is crucial to prevent gastrointestinal discomfort, a common side effect of metformin. Adequate hydration helps reduce the risk of gastrointestinal upset and ensures the medication is well-tolerated. Option A is generally true for metformin but is not as essential as maintaining proper hydration. Option B is important but not directly related to starting metformin. Option D is incorrect as a metallic taste in the mouth is not typically associated with metformin.
3. A client with a new diagnosis of hypothyroidism is being taught about medication management. Which of the following statements should the nurse include in the teaching?
- A. You should take your medication with a high-fiber meal.
- B. You should take your medication on an empty stomach.
- C. You should take your medication with a calcium supplement.
- D. You should take your medication before bedtime.
Correct answer: B
Rationale: The correct answer is B: 'You should take your medication on an empty stomach.' When educating a client with hypothyroidism, it is essential to advise taking thyroid medication on an empty stomach to enhance absorption and effectiveness. Taking the medication with food, especially high-fiber or with supplements like calcium, can interfere with absorption and reduce its efficacy. Therefore, it is crucial for the client to follow the recommendation of taking the medication on an empty stomach. Choices A, C, and D are incorrect because taking the medication with a high-fiber meal (Choice A) or with a calcium supplement (Choice C) can hinder absorption, and taking it before bedtime (Choice D) does not optimize absorption compared to taking it on an empty stomach.
4. During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?
- A. Back rub
- B. Counter-pressure
- C. Playing music
- D. Foot massage
Correct answer: B
Rationale: In cases where the fetus is in a posterior position causing severe pressure and pain in the lower back during labor, applying counter-pressure is the most effective nonpharmacological intervention. Counter-pressure helps lift the fetal head off the spinal nerve, offering relief to the client. This technique is evidence-based and recommended to alleviate discomfort associated with a posterior fetal position. Choices A, C, and D are not as effective in this situation. While a back rub or playing music may provide some comfort, they do not directly address the issue caused by the fetal head's position. Similarly, a foot massage may offer relaxation but may not significantly relieve the specific discomfort arising from the posterior fetal position and the associated lower back pain.
5. A client with a severe urinary tract infection (UTI) asks why both ciprofloxacin and phenazopyridine are needed. Which of the following responses should the nurse make?
- A. Phenazopyridine decreases adverse effects of ciprofloxacin.
- B. Combining phenazopyridine with ciprofloxacin shortens the course of therapy.
- C. The use of phenazopyridine allows for a lower dosage of ciprofloxacin.
- D. Ciprofloxacin treats the infection, and phenazopyridine treats pain.
Correct answer: D
Rationale: Ciprofloxacin is an antibiotic that treats the infection, while phenazopyridine is a urinary analgesic that relieves pain. Choice A is incorrect because phenazopyridine does not decrease adverse effects of ciprofloxacin; it primarily addresses pain. Choice B is incorrect because combining phenazopyridine with ciprofloxacin does not shorten the course of therapy; they serve different purposes. Choice C is incorrect because the use of phenazopyridine does not allow for a lower dosage of ciprofloxacin; they have independent roles in UTI management.
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