ATI LPN
LPN Fundamentals Final Exam Questions
Question 1 of 5
The nurse is providing care for a 2-month-old infant scheduled for a pyloromyotomy. Which of the following pre-operative actions can the nurse expect to perform? Select all that apply.
Correct Answer: D
Rationale: For a 2-month-old infant undergoing a pyloromyotomy to correct pyloric stenosis, pre-operative nursing actions focus on safety and preparation for anesthesia and surgery. Keeping the infant NPO (nothing by mouth) as ordered (D) is critical to prevent aspiration during anesthesia, a standard pre-operative protocol for all surgical patients, especially infants. Allowing breastfeeding 1 hour before surgery (A) contradicts NPO guidelines, risking complications like vomiting or aspiration, making it incorrect. Reviewing coagulation study results (B) is important, as infants with pyloric stenosis may have electrolyte imbalances affecting clotting, but it's not the most immediate action. Avoiding all pre-operative sedation (C) is impractical, as sedation may be needed based on medical orders, not universally avoided. Other options like beginning IV fluids (E) and placing an NG tube (F) are relevant but context-specific. Since the CSV requires one correct answer, D is chosen as the most universally applicable and critical action, ensuring the infant's safety by adhering to NPO status, a fundamental pre-operative standard.
Question 2 of 5
The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation but can be inaccurate with hypotension (C), as low blood pressure reduces peripheral perfusion, skewing readings. Fever (A) may increase metabolic demand but doesn't directly affect accuracy. Epilepsy (B) impacts neurological status, not perfusion. Respiratory failure (D) alters oxygenation but not oximetry reliability unless perfusion is compromised. C is correct. Rationale: Hypotension decreases blood flow to capillaries where oximeters detect hemoglobin saturation, leading to falsely low or erratic results, a known limitation per critical care monitoring standards. Nurses must correlate oximetry with clinical signs and possibly arterial blood gases (ABGs) in such cases, ensuring accurate respiratory assessment post-tracheostomy, unlike the other conditions which don't directly impair device function.
Question 3 of 5
A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?
Correct Answer: D
Rationale: Lowered consciousness (D) supports increased ICP post-craniotomy, reflecting brain compression. Weak pulse (A) or narrow pulse pressure (B) are late. Shallow breathing (C) isn't specific. D is correct. Rationale: LOC decline is an early, reliable ICP sign, guiding urgent intervention, per neurosurgical care standards.
Question 4 of 5
A client with a traumatic brain injury has a Glasgow Coma Scale score of 8. Which nursing intervention is most appropriate?
Correct Answer: A
Rationale: GCS of 8 indicates severe injury; preparing for intubation (A) protects the airway. Ambulation (B), fluids (C), or bath (D) are inappropriate. A is correct. Rationale: GCS ≤8 risks airway compromise, requiring intubation readiness, per trauma care standards, prioritizing safety.
Question 5 of 5
In Hildegard Peplau's Interpersonal Relations Model, the focus is on which of the following?
Correct Answer: A
Rationale: Hildegard Peplau's Interpersonal Relations Model centers on the individual, emphasizing the nurse-client relationship as a therapeutic tool for personal growth and problem-solving. Unlike models targeting communities or families, Peplau's framework views nursing as an interpersonal process where the nurse supports the client's emotional and health needs through phases like orientation and resolution. For instance, helping a client cope with anxiety post-diagnosis focuses on their unique experience, not broader societal dynamics. This individual focus distinguishes her theory, fostering tailored interventions that enhance client autonomy and well-being in clinical practice.