ATI LPN
LPN Pediatrics
1. Which of the following parameters is the LEAST reliable when assessing the perfusion status of a 2-year-old child?
- A. Capillary refill time
- B. Presence of peripheral pulses
- C. Skin color and temperature
- D. Systolic blood pressure
Correct answer: D
Rationale: Systolic blood pressure is the least reliable parameter when assessing perfusion status in a 2-year-old child. In young children, blood pressure measurements can be variable, affected by factors like anxiety or crying. Capillary refill time, presence of peripheral pulses, and skin color and temperature are more reliable indicators of perfusion status in this age group.
2. A client is having difficulty voiding after removal of an indwelling urinary catheter. What should the nurse do?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This action helps stimulate voiding post-catheterization by promoting relaxation and providing sensory input. Assessing for bladder distention after 6 hours (Choice A) is important but not the immediate intervention needed for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not effectively address the issue of post-catheterization voiding difficulty. Restricting the client's intake of oral fluids (Choice C) is not appropriate and can lead to dehydration, which is not helpful in promoting voiding.
3. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsening with deep breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.
4. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen
- B. Prepare the client for a thoracentesis
- C. Elevate the client’s lower extremities
- D. Administer anticoagulant therapy
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.
5. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?
- A. I know it may take several weeks before I start feeling better.
- B. I should avoid drinking alcohol while taking this medication.
- C. I will stop taking the medication as soon as I feel better.
- D. I should take the medication at the same time every day.
Correct answer: C
Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.
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