ATI LPN
LPN Fundamentals Questions
Question 1 of 5
The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.
Correct Answer: A
Rationale: Suctioning a tracheostomy requires precise interventions to ensure safety and efficacy. Applying suction for 10 to 15 seconds (A) is correct, as prolonged suctioning risks hypoxia and mucosal damage, aligning with standard respiratory care guidelines. Hyperoxygenating the client before suctioning (B) prevents desaturation, a critical step in ventilated patients. Setting suction pressure at $160 \mathrm{~mm} \mathrm{Hg}$ (C) is too high; typical adult settings are 80-120 mm Hg to avoid trauma. Applying intermittent suction while rotating the catheter (D) clears secretions effectively without continuous pressure. Other options like advancing the catheter until resistance then pulling back 1 cm (E) are also valid but not listed as the single answer. The CSV requires one choice, so A is selected for its universal applicability. Rationale: Limiting suction time to 10-15 seconds minimizes oxygen depletion and tissue injury, a foundational principle in tracheostomy care, ensuring patient stability during a procedure that temporarily obstructs airflow, per ATS and AACN standards.
Question 2 of 5
Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care?
Correct Answer: D
Rationale: Slow pupil reaction and rising systolic BP post-stroke indicate increased ICP (D), a common complication. Spinal (A) or hypovolemic shock (C) don't apply. Herniation (B) is a result. D is correct. Rationale: ICP from edema or bleeding requires urgent focus, per stroke management protocols, to prevent further brain damage.
Question 3 of 5
The nurse is caring for a client with a C6 spinal cord injury. Which activity should the nurse encourage to promote independence?
Correct Answer: B
Rationale: C6 SCI allows arm movement; feeding with adaptive utensils (B) promotes independence. Wheelchair (A) is mobility. Walking (C) or full dressing (D) exceed C6 ability. B is correct. Rationale: C6 function supports elbow flexion, enabling self-feeding with tools, per rehabilitation goals, enhancing autonomy.
Question 4 of 5
The lowest level of needs in Maslow's Hierarchy of Needs is which of the following?
Correct Answer: C
Rationale: In Maslow's Hierarchy, physiologic needs form the lowest level, encompassing essentials like air, water, food, and shelter required for survival. These foundational needs must be met before higher levels like safety, love, or self-esteem can be addressed, as a person cannot focus on security or relationships if starving or dehydrated. For example, a client struggling to breathe prioritizes oxygen over emotional support, illustrating this hierarchy's practical application in nursing. Misplacing higher needs below physiologic ones ignores human survival instincts, making this the correct baseline for assessing client priorities in care planning.
Question 5 of 5
A client asks you to explain viruses. Which of the following statements would be true and therefore best to include in your answer?
Correct Answer: C
Rationale: Explaining that viruses must enter living cells to reproduce is true and fundamental, distinguishing them from bacteria. Viruses lack cellular machinery, relying on host cells, unlike Candida, a fungus. They aren't the most common infectious agents universally, nor primarily intestinal. This fact educates the client accurately, aiding understanding of viral infections like flu, a key nursing teaching point.