ATI LPN
Patient Care Exam Questions Questions
Question 1 of 5
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
Correct Answer: B
Rationale: Ineffective airway clearance is priority in tracheoesophageal fistula. Aspiration risk from esophageal defect demands airway management, per ABCs. Dehydration , nutrition , and injury follow. B ensures breathing, making it key.
Question 2 of 5
While assessing a client with a casted right ankle and foot, the nurse notes the toes are more edematous than they were several hours ago and are cool to touch despite elevation of the foot above the level of the heart. Which action should the nurse take first?
Correct Answer: A
Rationale: Notifying the provider immediately is first. Increased edema and coolness despite elevation suggest vascular compromise (e.g., compartment syndrome), needing urgent evaluation, per protocol. More assessments delay, documentation is secondary, and heat worsens swelling. A ensures timely intervention, making it the initial step.
Question 3 of 5
A client who had a laparoscopic appendectomy 2 days ago reports pain at a level of 8 out of 10 at the incision site. Which action should the nurse take first?
Correct Answer: A
Rationale: Administering the prescribed analgesic is first for pain at 8/10 post-appendectomy. Severe pain needs rapid relief, per protocol, assuming PRN orders. Assessing , notifying , or breathing follow. A prioritizes comfort, making it the initial step.
Question 4 of 5
A client with a central venous catheter reports pain at the insertion site. Which action should the nurse take first?
Correct Answer: B
Rationale: Assessing the site for redness or swelling is first for pain at a CVC site. It identifies infection or thrombosis, guiding care, per nursing process. Flushing , medicating , or notifying follow assessment. B ensures accurate intervention, making it priority.
Question 5 of 5
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to
Correct Answer: A
Rationale: Maintaining the airway is the first action for anaphylaxis post-vaccine, indicated by itchy eyes, anxiety, and breathing difficulty, per emergency protocols. Airway compromise is life-threatening, prioritizing it over epinephrine , monitoring , or antihistamines , which follow. A ensures oxygenation, critical in this rapid-onset reaction.