ATI LPN
ATI PN Adult Medical Surgical 2019
1. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?
- A. Restrict the client's fluid intake.
- B. Keep the client's room warm.
- C. Ensure the client's bladder is emptied regularly.
- D. Limit the client's intake of high-fiber foods.
Correct answer: C
Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.
2. The Dietary Guidelines are published and revised by the U.S. Department of Agriculture in association with the:
- A. Department of Health and Human Services.
- B. National Institutes of Health.
- C. National Academy of Sciences.
- D. Food and Nutrition Board.
Correct answer: A
Rationale: The correct answer is A. The U.S. Department of Agriculture collaborates with the Department of Health and Human Services to publish and revise the Dietary Guidelines for Americans. This collaboration ensures that the guidelines encompass both agricultural and health aspects. Choices B, C, and D are incorrect as they are not directly involved in the publication and revision of the Dietary Guidelines. The National Institutes of Health focuses on medical research, the National Academy of Sciences provides independent scientific advice, and the Food and Nutrition Board is a part of the National Academies of Sciences, Engineering, and Medicine.
3. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?
- A. Hgb 12.8 g/dl.
- B. Potassium 4.2 mEq/L.
- C. RBC 4.4 million/mm3.
- D. Platelets 100,000/mm3.
Correct answer: D
Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.
4. A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?
- A. Encourage the parents to touch and explore the newborn's features
- B. Limit noise and interruptions in the delivery room
- C. Place the newborn at the client's breast
- D. Position the newborn skin-to-skin on the client's chest
Correct answer: D
Rationale: Positioning the newborn skin-to-skin on the client's chest is the priority action to promote warmth, regulate the newborn's heart rate and breathing, and enhance parent-infant bonding. This method facilitates early bonding, stabilizes the baby's temperature, and encourages breastfeeding initiation. Encouraging parents to touch and explore the newborn's features is important but not the priority at this moment. Limiting noise and interruptions can be beneficial but not as crucial as skin-to-skin contact for bonding. Placing the newborn at the client's breast is essential for breastfeeding but should come after the initial skin-to-skin contact for bonding and temperature regulation.
5. What is an example of a culturally sensitive response from a healthcare provider when a patient mentions feeling uncomfortable with a treatment plan?
- A. Asking why they feel this way
- B. Explaining that the treatment is standard
- C. Inviting the patient to share concerns
- D. Offering alternative treatments
Correct answer: C
Rationale: Inviting the patient to share concerns is an example of a culturally sensitive response as it acknowledges the patient's feelings and provides a safe space for them to express their discomfort. This approach shows respect for the patient's cultural beliefs and values by valuing their perspective. Choice A, asking why they feel this way, can be perceived as confrontational and may not encourage open communication. Choice B, explaining that the treatment is standard, dismisses the patient's feelings and does not address their discomfort. Choice D, offering alternative treatments, may be premature without fully understanding the patient's concerns first.
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