ATI LPN
ATI Fundamentals LPN Questions
Question 1 of 5
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
Question 2 of 5
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.
Question 3 of 5
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
Question 4 of 5
While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.
Question 5 of 5
Which one of the following four clients is most likely to tolerate pain best?
Correct Answer: C
Rationale: An athlete undergoing knee surgery likely tolerates pain best, motivated by career goals, unlike chronic arthritis, cancer grief, or migraines. Nurses consider this in pain management.