ATI LPN
Quizlet LPN Fundamentals Questions
Question 1 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 2 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 3 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.
Question 4 of 5
When writing goals/outcomes for clients, the nurse should do which of the following?
Correct Answer: C
Rationale: Involving the client in setting goals ensures outcomes reflect their values and needs, enhancing motivation and adherence. For example, a client with diabetes might prioritize dietary control over exercise, tailoring care to their lifestyle. Combining diagnoses or limiting them risks oversimplification, while team-driven goals may ignore client preferences. Client collaboration fosters autonomy and relevance like aiming for stable glucose levels making this the most effective approach for meaningful, achievable outcomes in nursing care planning.
Question 5 of 5
A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which one of the following criteria would enable the nurse to have access to the chart?
Correct Answer: D
Rationale: Only nurses directly involved in a client's care can access their chart, per privacy laws like HIPAA, ensuring confidentiality. Being unrelated, licensed, or having verbal permission doesn't grant rights without a care role. This protects client information, a legal and ethical duty in nursing.