ATI LPN
ATI PN Comprehensive Predictor
1. Which nursing action is a priority when caring for a client with heart failure?
- A. Encourage the client to drink fluids frequently
- B. Weigh the client daily to monitor fluid balance
- C. Increase fluid intake to prevent dehydration
- D. Limit the client's sodium intake
Correct answer: B
Rationale: Weighing the client daily is a priority action when caring for a client with heart failure because it helps monitor fluid balance. This monitoring is essential in managing heart failure as it allows healthcare providers to assess for signs of fluid retention or depletion, which are crucial in adjusting treatment plans. Encouraging the client to drink fluids frequently (Choice A) may worsen fluid overload in heart failure patients. Increasing fluid intake (Choice C) can exacerbate fluid retention. While limiting sodium intake (Choice D) is important in heart failure management, monitoring fluid balance through daily weighing takes precedence as a priority nursing action.
2. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
- A. Administer oxygen
- B. Stimulate the newborn
- C. Initiate positive pressure ventilation
- D. Continue routine monitoring
Correct answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.
3. What is the role of the nurse in postoperative care for a patient with a hip replacement?
- A. Monitor for signs of infection and administer pain relief
- B. Ensure the patient follows a low-calcium diet
- C. Ensure the patient uses crutches to avoid pressure on the hip
- D. Monitor for signs of deep vein thrombosis
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.
4. A client has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?
- A. I will start feeling better immediately after starting the medication
- B. I can expect to urinate frequently while on this medication
- C. I understand I may experience difficulty sleeping on this medication
- D. I should decrease my sodium intake while on this medication
Correct answer: C
Rationale: The correct answer is C. Difficulty sleeping is a common side effect of sertraline, an SSRI used to treat depression. Clients should be educated to expect this, especially during the early stages of treatment. Choice A is incorrect because sertraline may take a few weeks to show its full effect. Choice B is incorrect as increased urination is not a common side effect of sertraline. Choice D is unrelated to the side effects or management of sertraline.
5. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?
- A. Keep the client’s communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
- B. Keep the client’s communication confidential, but watch the client and their roommate closely
- C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
- D. Report the incident to the health care team but do not inform the client of the intention to do so
Correct answer: C
Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.
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