ATI LPN
ATI PN Comprehensive Predictor
1. What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?
- A. Edema, weight gain, shortness of breath
- B. Fever, cough, chest pain
- C. Increased heart rate, low blood pressure
- D. Increased blood pressure, jugular venous distention
Correct answer: A
Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.
2. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?
- A. Stomatitis
- B. Fatigue
- C. Wasting syndrome
- D. Lipodystrophy
Correct answer: B
Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.
3. When assessing a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?
- A. Albumin
- B. Calcium
- C. Glucose
- D. Alkaline phosphatase
Correct answer: C
Rationale: The most important laboratory value to monitor regularly in clients receiving total parenteral nutrition (TPN) is glucose. TPN solutions contain high concentrations of glucose, which can lead to hyperglycemia. Monitoring glucose levels is crucial to detect and prevent hyperglycemia, a common complication associated with TPN administration. Albumin (Choice A) levels are not typically affected by TPN administration. Calcium (Choice B) and alkaline phosphatase (Choice D) are not directly impacted by TPN and are not the primary values to monitor in TPN therapy.
4. Nurse R works on the geriatric medicine unit of the university hospital and provides care for numerous older adult clients nearing the end of life, many of whom have no-code orders. Which of the following situations is incompatible with the legal requirements for a no-code order?
- A. A client who is mentally competent has declared his wish to have a no-code order despite the availability of treatment options for his condition.
- B. A client has expressed her desire to have a no-code order but her daughter is adamantly opposed to it.
- C. A client clearly tells the nurse her desire to have a no-code order, which the nurse documents at the bedside.
- D. A client has been in a coma and the family has decided to put in place a no-code order.
Correct answer: C
Rationale: The correct answer is C. No-code orders require a written and signed order by a physician. Therefore, a client expressing the desire for a no-code order to a nurse, without a documented physician's order, is incompatible with legal requirements. Choices A and B are not incompatible as competent clients can make their own decisions, regardless of treatment options or family opposition. Choice D is also not incompatible as family decisions can be made on behalf of incompetent clients.
5. Your assessment of a newborn reveals cyanosis to the chest and face and a heart rate of 90 beats/min. What should you do first?
- A. Dry the infant briskly.
- B. Suction the mouth.
- C. Begin artificial ventilations.
- D. Begin chest compressions.
Correct answer: C
Rationale: In a newborn with cyanosis to the chest and face and a heart rate of 90 beats/min, the priority action is to begin artificial ventilations. A heart rate below 100 beats/min with cyanosis indicates a need for immediate respiratory support to improve oxygenation. Drying the infant briskly or suctioning the mouth may be necessary later but are not the initial priority. Chest compressions are not indicated as the heart rate is above 60 beats/min.
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