ATI LPN
LPN Nursing Fundamentals Questions
Question 1 of 5
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
Correct Answer: B
Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.
Question 2 of 5
A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document?
Correct Answer: A
Rationale: GCS assesses eye opening (1-4), verbal (1-5), and motor (1-6). No response (eyes closed, no verbalization, no movement) scores 1+1+1=3 (A). Higher scores (B, C, D) require responses. A is correct. Rationale: A score of 3 is the lowest GCS, indicating deep coma, critical for documenting severe brain injury and guiding urgent care, per trauma assessment standards.
Question 3 of 5
A client's wife has been informed by the physician that her spouse has a permanent C2-C3 spinal injury, which has resulted in permanent quadriplegia. The wife states that she does not want the physician or nursing staff to tell the client about his injury. The client is awake, alert, and oriented when he asks his nurse to tell him what has happened. The nurse has conflicting emotions about how to handle the situation and is experiencing:
Correct Answer: B
Rationale: The nurse's conflict between truth-telling and the wife's request is moral distress (B), feeling unable to act ethically. Autonomy (A) is patient rights. Doubt (C) is uncertainty. Courage (D) is acting despite fear. B is correct. Rationale: Moral distress arises from ethical dilemmas, common in nursing when values clash, per ethics frameworks, requiring resolution.
Question 4 of 5
A client with a traumatic brain injury has an intracranial pressure (ICP) of $15 \mathrm{mmHg}$ and a mean arterial pressure (MAP) of $90 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP)?
Correct Answer: B
Rationale: CPP = MAP - ICP; 90 - 15 = 75 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP of 75 mmHg is within normal (60-100), ensuring brain perfusion, per neurocritical care, critical for TBI outcomes.
Question 5 of 5
Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
Correct Answer: A
Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.