ATI LPN
LPN Pediatrics
1. When you attempt to assess a 22-year-old woman who has been sexually assaulted, she orders you not to touch her. Your MOST appropriate initial action should be to:
- A. obtain a signed refusal and return to service.
- B. transport the patient without performing an assessment.
- C. explain to the patient that she must be examined.
- D. ask a female EMT to attempt to assess the patient.
Correct answer: D
Rationale: In cases of sexual assault, it's important to respect the patient's wishes and provide a female EMT to attempt the assessment if the patient prefers.
2. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?
- A. Blood pressure 140/90 mm Hg
- B. Urine output of 40 mL/hr
- C. Temperature 38.2°C (100.8°F)
- D. Hemoglobin 8 g/dL
Correct answer: C
Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.
3. You are in a client’s home to attend to a delivery. Which of the following will you do first?
- A. Set up a sterile area
- B. Put on a clean gown and apron
- C. Cleanse the client’s vulva with soap and water
- D. Note the interval, duration and intensity of labor and contractions
Correct answer: D
Rationale: Assessment of the woman should be done first to determine whether she is having true labor and, if so, what stage of labor she is in.
4. A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct answer: C
Rationale: In cases of major depressive disorder where the client is non-participatory and withdrawn, sitting with the client and providing support without pressuring them to engage in activities like eating or therapy is crucial. This approach respects the client's current state, builds trust, and creates a supportive environment that can eventually lead to the client opening up and accepting help.
5. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?
- A. WBC count 11,000/mm³
- B. Hgb 11.2 g/dL
- C. Hct 34%
- D. Platelets 140,000/mm³
Correct answer: D
Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.
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