ATI LPN
Quizlet LPN Fundamentals Questions
Question 1 of 5
The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?
Correct Answer: B
Rationale: Bloody secretions during nasopharyngeal suctioning suggest trauma; checking suction pressure (B) identifies if excessive force (e.g., >120 mm Hg) caused it, allowing adjustment. Continuing (A) or vigorous suctioning (D) risks further damage. Coughing (C) may not be feasible. B is correct. Rationale: Adjusting pressure prevents additional injury, a proactive step per airway management standards, balancing secretion removal with safety.
Question 2 of 5
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolality is what?
Correct Answer: A
Rationale: Sodium (A) regulates extracellular osmolality by controlling water movement across membranes. Potassium (B), chloride (C), and calcium (D) have other roles. A is correct. Rationale: Sodium's osmotic effect maintains fluid balance, critical in assessing hydration and edema, per physiology principles, unlike other electrolytes with intracellular or signaling functions.
Question 3 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 4 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 5 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.