ATI LPN
LPN Fundamentals of Nursing Quizlet Questions
Question 1 of 5
The nurse is caring for a client with a history of congestive heart failure. The client's dyspnea has worsened over the past 2 hours. The nurse should:
Correct Answer: B
Rationale: Placing the client in high Fowler's position eases dyspnea in worsening congestive heart failure by reducing preload oxygen adjustment needs orders, Lasix requires confirmation, and coughing won't help acute fluid overload. Nurses prioritize positioning, monitoring respiratory status, aiding comfort in this cardiac emergency.
Question 2 of 5
The nurse is caring for a client with Addison's disease. Which finding is expected with this diagnosis?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?
Correct Answer: A
Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration.
Question 4 of 5
When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?
Correct Answer: C
Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood.
Question 5 of 5
A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?
Correct Answer: C
Rationale: In this scenario, option C - Apply a transparent dressing over the heel - is the correct intervention for a client with a stage 1 pressure ulcer on the right heel. Here's why: Transparent dressings provide a barrier against external contaminants while allowing visual inspection of the wound without disturbing it. This promotes a moist wound environment, which is conducive to healing in stage 1 pressure ulcers. Additionally, transparent dressings can protect the wound from friction and shear forces. Now, let's address why the other options are incorrect: A) Applying a heat lamp to the area for 20 minutes each day can increase the risk of further tissue damage and does not promote wound healing in stage 1 pressure ulcers. B) Changing the dressing on the heel every 12 hours may disrupt the wound healing process by interfering with the formation of granulation tissue and re-epithelialization. D) Using a water pressure mattress is not indicated for a stage 1 pressure ulcer on the heel. While pressure redistribution is important for preventing pressure ulcers, the treatment for an existing stage 1 ulcer involves maintaining a clean, moist environment with appropriate dressings. In an educational context, it is crucial for nurses to understand the rationale behind wound care interventions to provide evidence-based and effective care to clients. By selecting the appropriate dressing for a stage 1 pressure ulcer, nurses can support the healing process and prevent complications associated with pressure injuries.