ATI LPN
ATI PN Comprehensive Predictor 2020 Answers
1. What are common signs of hypoglycemia?
- A. Shakiness or Tremors
- B. Sweating
- C. Hunger
- D. Confusion or Irritability
Correct answer: A
Rationale: The correct signs of hypoglycemia include shakiness or tremors, sweating, and hunger. These symptoms indicate low blood sugar levels. Confusion or irritability are more associated with severe hypoglycemia, while the immediate treatment for hypoglycemia involves providing a source of glucose to raise blood sugar levels quickly.
2. What are the nursing considerations when administering blood products?
- A. Monitor vital signs and check for allergic reactions
- B. Verify blood type and compatibility before transfusion
- C. Monitor for signs of infection and sepsis
- D. Ensure consent is signed and prepare for possible reaction
Correct answer: A
Rationale: The correct answer is A: Monitor vital signs and check for allergic reactions. When administering blood products, monitoring vital signs such as blood pressure, heart rate, and temperature is crucial to detect any adverse reactions promptly. Checking for allergic reactions, such as hives, itching, or difficulty breathing, is essential to ensure patient safety. Choice B is incorrect because verifying blood type and compatibility is typically done by the laboratory before the blood is issued for transfusion. Choice C is not a direct nursing consideration during the administration of blood products. While monitoring for signs of infection and sepsis is important in general patient care, it is not specific to blood transfusions. Choice D is also incorrect as ensuring consent is signed and preparing for possible reactions are important but do not directly relate to the immediate nursing considerations during blood product administration.
3. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?
- A. The child is placed in a private room
- B. The staff removes a toy from the child's bed and takes it to the nurse's station
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack
- D. The staff uses standard precautions
Correct answer: A
Rationale: The correct answer is A. Private room placement is crucial when caring for a patient with hepatitis A to prevent the transmission of the disease to others. Placing the child in a private room helps contain the infection and protect other patients and staff. Choices B, C, and D are incorrect because removing a toy from the child's bed, offering specific snacks, or using standard precautions, while important in general care, are not specific measures required to prevent the spread of hepatitis A.
4. What are the early signs of sepsis in a patient?
- A. Increased heart rate and fever
- B. Low blood pressure and confusion
- C. Elevated blood sugar and sweating
- D. Increased urine output and abdominal pain
Correct answer: A
Rationale: The correct answer is A: Increased heart rate and fever. These are early signs of sepsis and indicate a systemic infection. It is crucial to identify these signs promptly to initiate appropriate treatment. Choice B is incorrect because low blood pressure and confusion are more indicative of severe sepsis or septic shock rather than early signs. Choice C is incorrect as elevated blood sugar and sweating are not typical early signs of sepsis. Choice D is also incorrect as increased urine output and abdominal pain are not early signs of sepsis.
5. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?
- A. Assess for bladder distention after 2 hours
- B. Encourage the client to try urinating in a sitting position
- C. Pour warm water over the client's perineum
- D. Restrict the client's fluid intake
Correct answer: C
Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.
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