ATI LPN
LPN Nursing Fundamentals Questions
Question 1 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 2 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.
Question 3 of 5
A client with a traumatic brain injury has an intracranial pressure (ICP) of $15 \mathrm{mmHg}$ and a mean arterial pressure (MAP) of $90 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP)?
Correct Answer: B
Rationale: CPP = MAP - ICP; 90 - 15 = 75 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP of 75 mmHg is within normal (60-100), ensuring brain perfusion, per neurocritical care, critical for TBI outcomes.
Question 4 of 5
Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
Correct Answer: A
Rationale: A wellness nursing diagnosis best describes a clinical judgment of transitioning to a higher wellness level, focusing on enhancing health beyond mere absence of disease. Unlike pathology-based diagnoses, it identifies potential for growth like improving nutrition in a healthy client reflecting nursing's preventive role. Judging no pathology or more wellness than illness is narrower, missing the forward-looking aspect, while family strengths support interventions but aren't the diagnosis. This perspective encourages proactive care, aligning with wellness models to elevate client health.
Question 5 of 5
You would refer to the early phase of scar tissue formation as which of the following kinds of tissue?
Correct Answer: C
Rationale: The early phase of scar tissue formation is granulation tissue, rich in new blood vessels and collagen, aiding wound healing. Keloids are excessive scars, cicatrix is the final scar, and fibrous tissue is later-stage. Recognizing granulation informs nursing wound care, ensuring proper healing progression.