ATI LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. Which nursing intervention is best for a client with constipation?
- A. Encourage the client to remain in bed to avoid straining
- B. Administer a stool softener as prescribed
- C. Increase fiber intake through dietary changes
- D. Encourage regular exercise to promote bowel movement
Correct answer: C
Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.
2. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only as necessary
- B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
- C. Keep the dressing tray on a nearby surface
- D. Avoid speaking during the procedure
Correct answer: B
Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.
3. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?
- A. Administer pain medication
- B. Perform a fundal massage
- C. Check the baby's heart rate
- D. Apply an ice pack
Correct answer: B
Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.
4. The client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Serum electrolytes
- D. Liver function tests
Correct answer: B
Rationale: Activated partial thromboplastin time (aPTT) is the correct laboratory test to monitor the effectiveness of anticoagulant therapy, especially with heparin. A prolonged aPTT indicates effective anticoagulation, reducing the risk of further clot formation in the client with deep vein thrombosis (DVT). The other options, such as complete blood count (CBC), serum electrolytes, and liver function tests, do not directly assess the therapeutic effectiveness of anticoagulant therapy. Therefore, the correct answer is B.
5. A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?
- A. Administer a fluid bolus of 500 ml.
- B. Notify the healthcare provider immediately.
- C. Administer a diuretic.
- D. Continue to monitor the CVP.
Correct answer: B
Rationale: A CVP of 15 mm Hg is higher than normal, indicating possible fluid overload or heart failure, which needs immediate attention. Notifying the healthcare provider is crucial as they can evaluate the client's condition, order appropriate interventions, and prevent potential complications.
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