ATI LPN
LPN Nursing Fundamentals Questions
Question 1 of 5
The nurse is planning care for a client with a chronic illness. Which intervention reflects tertiary prevention?
Correct Answer: B
Rationale: Tertiary prevention optimizes life with a chronic illness, reducing its impact post-diagnosis. Teaching strategies for living with it like pacing activities for arthritis helps the client adapt, minimizing disability and enhancing function, a nursing priority. Screening for depression is secondary, detecting new issues, not managing the existing one. An annual flu vaccine is primary, preventing unrelated illness, not addressing the chronic condition's effects. Educating about transmission fits infectious cases, not all chronic ones. This intervention tailored coping reflects nursing's role in rehabilitation, ensuring clients thrive despite limits. For instance, teaching a heart failure client fluid management cuts readmissions, aligning with tertiary care's focus on sustaining quality of life through practical, illness-specific support.
Question 2 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 3 of 5
The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?
Correct Answer: B
Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.
Question 4 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 5 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.