ATI LPN
Patient Care Exam Questions Questions
Question 1 of 5
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to
Correct Answer: A
Rationale: Maintaining the airway is the first action for anaphylaxis post-vaccine, indicated by itchy eyes, anxiety, and breathing difficulty, per emergency protocols. Airway compromise is life-threatening, prioritizing it over epinephrine , monitoring , or antihistamines , which follow. A ensures oxygenation, critical in this rapid-onset reaction.
Question 2 of 5
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
Correct Answer: C
Rationale: Advising parents to ignore breath-holding is best. It's a benign tantrum behavior; reflex breathing resumes, per pediatric standards. CPR is unnecessary, giving in reinforces behavior, and reasoning is ineffective at this age. C prevents escalation safely.
Question 3 of 5
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
Correct Answer: C
Rationale: Debriding eschar is the appropriate goal for a heel ulcer with black tissue. Eschar removal promotes healing, per wound care standards. Granulation isn't present, infection may follow debridement, and keeping eschar delays recovery. C addresses the primary barrier.
Question 4 of 5
During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and tongue. Which of the following would provide the most valuable data for nursing assessment?
Correct Answer: A
Rationale: Inspecting the mouth and throat provides the most valuable data. Sticky formula suggests thrush (Candida), requiring visual confirmation, per pediatric assessment. Cultures follow inspection, flushing is therapeutic, and wiping risks irritation. A guides diagnosis.
Question 5 of 5
The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
Correct Answer: B
Rationale: Removing the nitroglycerine patch after 12 hours prevents drug tolerance . A nitrate-free interval maintains efficacy, per cardiac pharmacology. Irritation , headaches , and hypotension occur but tolerance affects treatment. B ensures therapeutic benefit.