ATI LPN
ATI PN Comprehensive Predictor
1. What is the priority nursing action for a patient with an acute asthma attack?
- A. Administer a bronchodilator
- B. Monitor oxygen saturation
- C. Position the patient in a high Fowler's position
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator. During an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators are the first-line treatment for asthma attacks as they help dilate the bronchioles, allowing for better airflow. Monitoring oxygen saturation is important but not the priority when the patient is in distress. Placing the patient in a high Fowler's position can help with breathing but is not the initial priority. Calling for assistance can be done after initiating the appropriate treatment.
2. 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.
3. In the treatment of an infected hematoma, which of the following is NOT recommended?
- A. Incision and drainage
- B. Systemic antibiotics
- C. A and B
- D. Vitamin E
Correct answer: D
Rationale: Vitamin E is not a standard treatment for infected hematomas. The primary interventions for infected hematomas typically involve incision and drainage to remove infected fluid and debris, along with the administration of systemic antibiotics to combat the infection. Vitamin E does not play a significant role in the treatment of infected hematomas and is therefore not recommended as a primary treatment option. Choice A (Incision and drainage) and Choice B (Systemic antibiotics) are recommended treatments for infected hematomas as they help in removing infected fluid and combating the infection, respectively. Therefore, the correct answer is D, Vitamin E.
4. A nurse is providing care for an older adult client who has been admitted to the hospital with liver cirrhosis. The client has expressed to the nurse his concerns that the details of his condition and treatment remain confidential, and that written documentation not 'get out there.' How can the nurse best respond to the client's concerns?
- A. Anything that is discussed between us is confidential and will not be shared with anyone else.
- B. The Health Insurance Portability and Accountability Act ensures that your medical records will not leave this hospital.
- C. Provided you signed a directive on admission, your records will not be made public.
- D. The law protects your right to confidentiality and protects your health information from being released into unintended hands.
Correct answer: D
Rationale: The correct answer is D. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects individuals' right to confidentiality and safeguards health information from being accessed by unauthorized individuals. Assuring the client that the law protects their right to confidentiality and prevents their health information from being released into unintended hands is the best response. Choice A is too broad and may not cover all aspects of confidentiality. Choice B only mentions medical records staying within the hospital, which does not address the client's concern about written documentation. Choice C incorrectly implies that a signed directive is needed for confidentiality, which is not true under HIPAA regulations.
5. While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?
- A. Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
- B. Keep the newborn in a shirt while under the phototherapy light.
- C. Apply a light moisturizing lotion to the newborn's skin.
- D. Turn and reposition the newborn every 4 hours while undergoing phototherapy.
Correct answer: A
Rationale: It is crucial to cover the newborn's eyes with an opaque eye mask to prevent damage to the retinas and corneas from the phototherapy light. The eyes are particularly sensitive to the light used in phototherapy, and shielding them helps protect the newborn's delicate eyes from potential harm. Choice B is incorrect because the newborn should be undressed to maximize skin exposure to the phototherapy light. Choice C is incorrect because lotions or oils can interfere with the effectiveness of phototherapy. Choice D is incorrect because the newborn should be kept as still as possible to maximize exposure to the light.
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