ATI LPN
ATI Comprehensive Predictor PN
1. What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
2. The nurse is caring for a client diagnosed with deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care to prevent the complication of pulmonary embolism?
- A. Encourage ambulation as tolerated.
- B. Administer anticoagulants as prescribed.
- C. Apply cold compresses to the affected area.
- D. Encourage the use of incentive spirometry.
Correct answer: B
Rationale: Administering anticoagulants as prescribed is crucial in preventing the complication of pulmonary embolism in clients with deep vein thrombosis. Anticoagulants help prevent the formation of new clots and the enlargement of existing ones, thereby reducing the risk of a pulmonary embolism. Encouraging ambulation as tolerated is beneficial for preventing complications related to immobility, but it is not the primary intervention to prevent pulmonary embolism in this case. Applying cold compresses to the affected area may help with pain and swelling but does not address the prevention of pulmonary embolism. Encouraging the use of incentive spirometry is more relevant in preventing respiratory complications such as atelectasis, not specifically pulmonary embolism.
3. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. Client with cystic fibrosis who has a thick productive cough and reports thirst
- B. Client with gastroenteritis who is lethargic and confused
- C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
- D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic
Correct answer: B
Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.
4. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?
- A. Decerebrate posturing.
- B. Hypervigilance.
- C. Absence of deep tendon reflexes.
- D. Glasgow Coma Scale score of 15.
Correct answer: A
Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.
5. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?
- A. Recent blood transfusion
- B. Allergy to penicillin
- C. Minor acute illness
- D. Low-grade fever
Correct answer: A
Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.
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