ATI LPN
LPN Fundamentals Questions
Question 1 of 5
The nurse is caring for a client who has a terminal illness and is approaching death. Which intervention reflects health promotion at this stage of the client's life?
Correct Answer: B
Rationale: For a terminally ill client nearing death, health promotion shifts from cure to comfort and dignity, aligning with holistic care. Arranging hospice services supports this by providing pain relief, emotional support, and family assistance promoting quality of life in the final stage, not prolonging it. Teaching infection prevention or encouraging exercise fits earlier prevention levels, irrelevant here as the focus isn't averting illness but easing suffering. Screening for other conditions adds burden without benefit, as the terminal prognosis overshadows new diagnoses. Hospice reflects nursing's role in tertiary prevention mitigating decline and enhancing well-being amid inevitability. For instance, managing dyspnea or anxiety via hospice ensures peace, not futile resistance, embodying health promotion's adaptability to life's end, where comfort becomes the ultimate health goal.
Question 2 of 5
The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.
Correct Answer: A
Rationale: Suctioning a tracheostomy requires precise interventions to ensure safety and efficacy. Applying suction for 10 to 15 seconds (A) is correct, as prolonged suctioning risks hypoxia and mucosal damage, aligning with standard respiratory care guidelines. Hyperoxygenating the client before suctioning (B) prevents desaturation, a critical step in ventilated patients. Setting suction pressure at $160 \mathrm{~mm} \mathrm{Hg}$ (C) is too high; typical adult settings are 80-120 mm Hg to avoid trauma. Applying intermittent suction while rotating the catheter (D) clears secretions effectively without continuous pressure. Other options like advancing the catheter until resistance then pulling back 1 cm (E) are also valid but not listed as the single answer. The CSV requires one choice, so A is selected for its universal applicability. Rationale: Limiting suction time to 10-15 seconds minimizes oxygen depletion and tissue injury, a foundational principle in tracheostomy care, ensuring patient stability during a procedure that temporarily obstructs airflow, per ATS and AACN standards.
Question 3 of 5
The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning?
Correct Answer: B
Rationale: Clear breath sounds (B) best determine suctioning effectiveness, indicating secretion clearance. Pink skin (A), comfort (C), or high Sao2 (D) are supportive but less direct. B is correct. Rationale: Audible lung clarity confirms airway patency, the primary suctioning goal, per respiratory assessment standards.
Question 4 of 5
Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?
Correct Answer: D
Rationale: Slow pupil reaction and rising systolic BP post-stroke indicate increased ICP (D), a common complication. Spinal (A) or hypovolemic shock (C) don't apply. Herniation (B) is a result. D is correct. Rationale: ICP from edema or bleeding requires urgent focus, per stroke management protocols, to prevent further brain damage.
Question 5 of 5
The nurse is caring for a client with a C6 spinal cord injury. Which activity should the nurse encourage to promote independence?
Correct Answer: B
Rationale: C6 SCI allows arm movement; feeding with adaptive utensils (B) promotes independence. Wheelchair (A) is mobility. Walking (C) or full dressing (D) exceed C6 ability. B is correct. Rationale: C6 function supports elbow flexion, enabling self-feeding with tools, per rehabilitation goals, enhancing autonomy.