ATI LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. What is the most appropriate intervention for a client with phlebitis at the IV site?
- A. Apply a warm compress to the site
- B. Discontinue the IV and notify the provider
- C. Increase the IV flow rate to prevent dehydration
- D. Monitor the site for signs of infection
Correct answer: B
Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.
2. The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
- A. Lanugo mostly gone, little vernix remaining on the body
- B. Prominent clitoris, enlarging labia minora, patent anus
- C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
- D. Skin opaque, cracking at wrists and ankles, no visible vessels
Correct answer: B
Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.
3. A nurse is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum potassium
- C. Signs of superinfection
- D. Blood glucose
Correct answer: C
Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.
4. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?
- A. Instruct the client to rest completely and avoid all self-care tasks
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to complete all self-care tasks
- D. Ask the client's family to assist with self-care tasks
Correct answer: B
Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.
5. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsening with deep breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.
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