ATI LPN
LPN Fundamentals Final Exam Questions
Question 1 of 5
A client who is dying states to the nurse, 'I'm not ready to go yet; there's so much left to do.' Which nursing action promotes the client's health at this time?
Correct Answer: B
Rationale: When a dying client expresses unfinished business, promoting health means supporting emotional and spiritual peace, not physical longevity. Asking what remains undone maybe reconciling with a loved one or recording memories and planning to address it empowers the client, reducing distress and fostering closure. This aligns with nursing's holistic focus, prioritizing psychological well-being at life's end over false cures. Reassuring without action dismisses their fears, while life-prolonging strategies ignore the terminal reality, potentially increasing frustration. Calling family hastily might overwhelm, not directly tackling the client's needs. By facilitating resolution like arranging a call to a estranged child the nurse promotes dignity and acceptance, key to health in dying, ensuring the client's final moments reflect their values, not just physical care.
Question 2 of 5
The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?
Correct Answer: C
Rationale: During nasotracheal suctioning, coughing (C) indicates adequate tolerance, as it's a natural reflex to clear airways without distress. Cyanosis (A) signals hypoxia, a complication. Bloody secretions (B) suggest trauma, not tolerance. A heart rate drop from 78 to 54 (D) may indicate vagal stimulation, a potential adverse effect. C is correct. Rationale: Coughing reflects an intact airway defense mechanism, showing the client can respond without decompensation, per respiratory nursing protocols. Other signs like cyanosis or bradycardia warrant stopping the procedure to reassess, as they indicate oxygenation or cardiac compromise, making C the safest indicator of tolerance.
Question 3 of 5
The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation but can be inaccurate with hypotension (C), as low blood pressure reduces peripheral perfusion, skewing readings. Fever (A) may increase metabolic demand but doesn't directly affect accuracy. Epilepsy (B) impacts neurological status, not perfusion. Respiratory failure (D) alters oxygenation but not oximetry reliability unless perfusion is compromised. C is correct. Rationale: Hypotension decreases blood flow to capillaries where oximeters detect hemoglobin saturation, leading to falsely low or erratic results, a known limitation per critical care monitoring standards. Nurses must correlate oximetry with clinical signs and possibly arterial blood gases (ABGs) in such cases, ensuring accurate respiratory assessment post-tracheostomy, unlike the other conditions which don't directly impair device function.
Question 4 of 5
A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?
Correct Answer: D
Rationale: Lowered consciousness (D) supports increased ICP post-craniotomy, reflecting brain compression. Weak pulse (A) or narrow pulse pressure (B) are late. Shallow breathing (C) isn't specific. D is correct. Rationale: LOC decline is an early, reliable ICP sign, guiding urgent intervention, per neurosurgical care standards.
Question 5 of 5
A client with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which nursing intervention is most appropriate?
Correct Answer: A
Rationale: GCS of 8 indicates severe injury; preparing for intubation (A) protects the airway. Ambulation (B), fluids (C), or bath (D) are inappropriate. A is correct. Rationale: GCS ≤8 risks airway compromise, requiring intubation readiness, per trauma care standards, prioritizing safety.