ATI LPN
LPN Nursing Fundamentals Quizlet Questions
Question 1 of 5
The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status?
Correct Answer: B
Rationale: A respiratory rate of 18 (B) indicates adequate status in a tracheostomy client with thick secretions. Saturation of $89\%$ (A) is low. Secretions (C) or blood (D) suggest issues. B is correct. Rationale: Normal rate reflects effective ventilation despite secretions, per respiratory assessment criteria.
Question 2 of 5
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?
Correct Answer: B
Rationale: Necrotizing fasciitis, a flesh-eating infection, prioritizes skin integrity (B) due to rapid tissue destruction. Fluid (A), mobility (C), and urination (D) are secondary. B is correct. Rationale: Skin breakdown drives sepsis risk, requiring urgent debridement and antibiotics, per infectious disease care, over other systemic concerns.
Question 3 of 5
A client with a T2 spinal cord injury reports a sudden onset of flushing and sweating above the level of injury. Which condition does the nurse suspect?
Correct Answer: B
Rationale: Flushing and sweating above T2 injury suggest autonomic dysreflexia (B) from a stimulus below. Neurogenic (A) or hypovolemic (C) shock has different signs. Spinal shock (D) is early flaccidity. B is correct. Rationale: Dysreflexia causes upper-body symptoms from sympathetic activation, per SCI care, needing trigger identification.
Question 4 of 5
When the nurse problem solves and has implemented a solution from several solutions identified, the nurse most needs to do which of the following things?
Correct Answer: C
Rationale: After implementing a solution, evaluating its effectiveness is the most critical step in the nursing process. This ensures the chosen intervention meets the client's needs, allowing adjustments if goals aren't achieved. Discarding unused solutions ignores potential future relevance, while implementing a second solution without evaluation risks inefficiency or harm. Declaring problem-solving complete without assessing outcomes neglects accountability and client safety. Evaluation involves observing results like reduced pain after medication and comparing them to expected outcomes, refining care as needed. This reflective practice upholds evidence-based care, ensuring interventions are successful and responsive to the client's evolving condition.
Question 5 of 5
Which of the following interventions on the part of the nurse would most help a confused ambulatory client find their room?
Correct Answer: B
Rationale: For a confused ambulatory client, placing a picture on the door best aids room recognition, leveraging visual memory over abstract numbers or verbal cues. Large numbers help but may not register with confusion, hourly reorientation is temporary, and pinning numbers risks loss. A familiar image like a family photo serves as a consistent, intuitive marker, enhancing independence and reducing disorientation in nursing care.