ATI LPN
LPN Fundamentals Exam 1 Quizlet Questions
Question 1 of 5
The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?
Correct Answer: A
Rationale: During a seizure from subdural hematoma, assessing the airway (A) is the first action to ensure oxygenation, per ABC priority. Padding rails (B) is safety but secondary. Notifying (C) or leaving (D) delays care. A is correct. Rationale: Seizures risk airway obstruction; immediate airway assessment prevents hypoxia, a fundamental nursing action in neurological emergencies, guiding subsequent steps like positioning or escalation.
Question 2 of 5
The nurse is caring for a client with a spinal cord injury at C4. Which complication should the nurse monitor for as a priority?
Correct Answer: A
Rationale: C4 SCI risks respiratory failure (A) from phrenic nerve impairment. Retention (B), ulcers (C), or incontinence (D) are secondary. A is correct. Rationale: Breathing loss is immediate and life-threatening, per SCI priorities, requiring ventilatory support.
Question 3 of 5
When reading the nursing-care plan of a newly assigned client prior to caring for this client, the LPN/LVN will notice that potential problems are stated using how many parts in the statement?
Correct Answer: B
Rationale: In a nursing-care plan, potential problems, or risk diagnoses, are stated in two parts: the risk diagnosis (e.g., 'Risk for Falls') and the related factors (e.g., 'related to impaired mobility'). This format, per NANDA guidelines, identifies the potential issue and its cause, guiding preventive interventions. One-part statements lack context, while three- or four-part formats apply to actual diagnoses with defining characteristics. For an LPN/LVN, recognizing this structure ensures clarity in addressing risks, like monitoring a client prone to falling due to weakness.
Question 4 of 5
Which of the following situations represents the best example of passive immunity?
Correct Answer: B
Rationale: Passive immunity involves receiving pre-formed antibodies, best exemplified by an infant getting maternal antibodies via breast milk. Vaccinations trigger active immunity, infection produces personal antibodies, and antibiotics treat bacteria, not immunity. This natural transfer protects newborns, a concept nurses teach in infant care.
Question 5 of 5
The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do prior to the examination?
Correct Answer: A
Rationale: Emptying the bladder before an abdominal assessment prevents distension from interfering with palpation or auscultation, most critical for accuracy. Equipment, position, and dressings follow. Nurses ensure this for reliable findings.