ATI LPN
Quizlet LPN Fundamentals Questions
Question 1 of 5
The nurse cares for an older adult client with congestive heart failure following a myocardial infarction. The client reports having difficulty breathing and states, 'I feel as if I am drowning when I lie down.' Which complication does the nurse recognize as contributing to this assessment finding?
Correct Answer: C
Rationale: The client's symptoms difficulty breathing and a drowning sensation when lying down (orthopnea) point to pulmonary edema (C), a complication of congestive heart failure (CHF) post-myocardial infarction (MI). In CHF, the heart's pumping fails, causing fluid to back up into the lungs, worsening when supine due to increased venous return. Myocardial infarction (A) is the cause, not the complication. Panic attack (B) may mimic dyspnea but lacks the positional clue. Left ventricular hypertrophy (D) contributes to CHF but isn't the direct issue. C is correct. Rationale: Pulmonary edema's hallmark is fluid in alveoli, causing respiratory distress and orthopnea, a classic CHF progression post-MI, requiring urgent intervention like diuretics, unlike anxiety or structural changes.
Question 2 of 5
The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply.
Correct Answer: D
Rationale: Increased ICP from head trauma manifests as decreased level of consciousness (D), a key sign of brain compression. Vomiting (A) and irritability (B) are early indicators. Hypotension (C) is late, not initial. D is correct for CSV. Rationale: LOC decline reflects worsening ICP, a critical progression requiring immediate action like imaging or decompression, per neurotrauma standards, distinguishing it from earlier symptoms.
Question 3 of 5
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolality is what?
Correct Answer: A
Rationale: Sodium (A) regulates extracellular osmolality by controlling water movement across membranes. Potassium (B), chloride (C), and calcium (D) have other roles. A is correct. Rationale: Sodium's osmotic effect maintains fluid balance, critical in assessing hydration and edema, per physiology principles, unlike other electrolytes with intracellular or signaling functions.
Question 4 of 5
The nurse is caring for a client with a spinal cord injury who is experiencing muscle spasticity. The healthcare provider prescribes baclofen. The nurse should monitor the client for which adverse effect of this medication?
Correct Answer: B
Rationale: Baclofen, a muscle relaxant for SCI spasticity, commonly causes drowsiness (B) due to CNS depression. Hyperglycemia (A), hypertension (C), or tachycardia (D) aren't typical. B is correct. Rationale: Sedation is a frequent side effect, requiring monitoring for safety, per pharmacology, especially in SCI patients with altered mobility.
Question 5 of 5
The newly licensed practical/vocational nurse begins work on a hospital unit where LPNs/LVNs are allowed to start intravenous fluids. The physician orders intravenous fluids to be started on one of this nurse's assigned clients. Which of the following actions would be most necessary on the part of this newly hired and newly licensed nurse before starting an intravenous on the client?
Correct Answer: A
Rationale: For a newly licensed practical/vocational nurse, ensuring competence and compliance before starting intravenous fluids is paramount. Checking hospital policy and certification requirements is the most necessary step because it confirms the nurse's legal scope of practice and institutional guidelines. Hospitals often have specific protocols dictating who can perform procedures like IV initiation, including any required training or certification beyond basic licensure. This step protects the client from potential harm due to inexperience and shields the nurse from liability if untrained. Asking another nurse for supervision or consulting an instructor might supplement skill verification but doesn't address formal authorization. Taking a continuing-education course is proactive but impractical as an immediate prerequisite. This action aligns with professional responsibility and patient safety, ensuring the nurse operates within established boundaries before proceeding.