ATI LPN
Nursing Fundamental Physical Assessment LPN Questions
Question 1 of 5
The nurse is caring for a client who has a strong family history of colon cancer. Which nursing intervention reflects secondary prevention?
Correct Answer: B
Rationale: Secondary prevention detects disease early, crucial for a client with a colon cancer family history. Screening via colonoscopy recommended from age 45 or earlier with risk spots polyps or cancer before symptoms, enabling removal or treatment, a nursing-coordinated action. High-fiber diet and smoking cessation are primary, preventing onset, not detecting. Genetic counseling assesses risk but isn't screening. Colonoscopy's precision cutting mortality by catching 60-70% of cancers early, per research makes it secondary prevention's gold standard here. Nursing ensures this high-risk client gets timely testing, aligning with prevention's focus on preemptive action, leveraging family history to avert late-stage diagnosis in a community or clinic setting.
Question 2 of 5
A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour?
Correct Answer: A
Rationale: Lorazepam (A), a sedative, may delay weaning by depressing respiratory drive. Furosemide (B), digoxin (C), and metoclopramide (D) don't directly affect this. A is correct. Rationale: Sedation impairs spontaneous breathing, critical for weaning, per ventilator management protocols.
Question 3 of 5
A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response?
Correct Answer: D
Rationale: Injury above the phrenic nerve (C3-C5) causes respiratory paralysis (D) by disrupting diaphragm innervation. Fibrillation (A) or vagus issues (B) aren't direct. Sensation/paralysis (C) is incomplete. D is correct. Rationale: Phrenic nerve loss halts breathing, a primary concern in high spinal injuries, per trauma care.
Question 4 of 5
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?
Correct Answer: C
Rationale: In multiple trauma, quality of respirations and pulses (C) assess airway and circulation, per ABCs. LOC/pupils (A), pain/BP (B), and wounds (D) follow. C is correct. Rationale: Breathing and perfusion are immediate life threats in crush injuries, guiding resuscitation, per trauma triage standards.
Question 5 of 5
The nurse is caring for a client with a spinal cord injury who is receiving intravenous fluids. Which finding indicates that the client is experiencing fluid overload?
Correct Answer: A
Rationale: Crackles (A) indicate fluid overload in SCI from excess IV fluids entering alveoli. Normal BP (B), pulse (C), or output (D) don't suggest this. A is correct. Rationale: Pulmonary edema from overload requires fluid adjustment, per critical care monitoring, critical in immobile SCI patients.