ATI LPN
ATI PN Comprehensive Predictor
1. What is the proper technique for measuring a patient's blood pressure?
- A. Place the cuff at heart level and listen for Korotkoff sounds
- B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
- C. Use a manual sphygmomanometer and measure blood pressure on both arms
- D. Monitor pulse rate and apply pressure to the brachial artery
Correct answer: A
Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.
2. How should a healthcare professional monitor a patient receiving IV potassium?
- A. Monitor ECG for dysrhythmias
- B. Monitor urine output
- C. Monitor serum potassium levels
- D. All of the above
Correct answer: D
Rationale: When a patient is receiving IV potassium, it is crucial to monitor various parameters to ensure patient safety. Monitoring the ECG helps in identifying any potential dysrhythmias that may occur due to potassium imbalances. Monitoring urine output is important as potassium levels can affect renal function. Monitoring serum potassium levels is essential to assess the effectiveness of the IV potassium therapy. Therefore, all the options - monitoring ECG for dysrhythmias, urine output, and serum potassium levels - are necessary when administering IV potassium, making 'All of the above' the correct answer. Choices A, B, and C are not individually sufficient as they each address different aspects of patient monitoring when receiving IV potassium.
3. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?
- A. Provide the client with distractions such as television
- B. Administer pain medication around the clock
- C. Teach the client relaxation techniques
- D. Perform massage therapy on the client
Correct answer: C
Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.
4. 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.
5. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?
- A. Encourage the client to eat high-protein foods
- B. Encourage the client to drink 2 liters of fluid daily
- C. Instruct the client to use a soft toothbrush
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: C
Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.
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