ATI LPN
Nursing Fundamentals Exam for LPN Questions
Question 1 of 5
A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Increased ICP post-CVA shows Cushing's triad: bradycardia, hypertension, and widened pulse pressure. Pulse 50, BP 140/60 (A) fits this. B has high diastolic. C is near normal. D suggests shock. A is correct. Rationale: Bradycardia and widened pulse pressure reflect ICP's brainstem effect, a critical sign per stroke monitoring.
Question 2 of 5
The nurse is caring for a client with a traumatic brain injury. Which assessment finding indicates that the client is experiencing Cushing's triad?
Correct Answer: A
Rationale: Cushing's triad (hypertension, widened pulse pressure, bradycardia) from ICP is seen in BP 180/60, pulse 50 (A). Others (B, C, D) don't match. A is correct. Rationale: Triad reflects brainstem compression, a late brain injury sign, per neurocritical care, requiring urgent intervention.
Question 3 of 5
Using Strader's seven-step decision-making process, the nurse needs to first identify the purpose. What must the nurse do next?
Correct Answer: C
Rationale: In Strader's seven-step decision-making process, after identifying the purpose, setting the criteria is the next logical step. This involves defining standards or goals like pain reduction or improved mobility that solutions must meet, providing a clear framework for evaluation. Deciding who's involved or enlisting client cooperation might follow but isn't immediate; the nurse must first establish what success looks like. Identifying solutions comes later, after criteria are set to guide options. For example, if the purpose is to manage a client's dyspnea, criteria might include oxygen saturation levels, ensuring subsequent steps align with measurable outcomes. This structured approach enhances decision-making precision in nursing practice.
Question 4 of 5
When assessing the noise level that clients are exposed to, the nurse is aware that levels below which of the following number of decibels is usually safe in terms of hearing?
Correct Answer: A
Rationale: Noise levels below 85 decibels are generally safe for hearing, per occupational and health standards. Prolonged exposure above this like 95 or higher risks damage, while 110 or 120 is immediately harmful. Nurses assess this to protect clients, especially in hospitals where equipment or activity might elevate levels. Maintaining a quiet environment below 85 supports healing and prevents auditory stress, a key environmental consideration in care.
Question 5 of 5
Tissue in the urinary bladder called transitional epithelium is best described in which of the following ways?
Correct Answer: D
Rationale: Transitional epithelium changes shape with bladder fullness, stretching thin when full, a unique adaptation. It's stratified, not single-layered, and lacks special elastic substances. This aids nursing assessment of urinary function.