ATI LPN
ATI Fundamentals LPN Questions
Question 1 of 5
The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?
Correct Answer: D
Rationale: A stuck catheter with coughing and wheezing suggests obstruction or bronchospasm; disconnecting the suction source (D) is the priority to relieve pressure and attempt removal. Calling a code (A) or provider (C) delays action. Bronchodilators (B) treat wheezing but not the immediate issue. D is correct. Rationale: Disconnecting stops suction trauma, allowing catheter withdrawal and airway reassessment, a critical first step per emergency airway protocols.
Question 2 of 5
The nurse is teaching a client who underwent a hypophysectomy for hypopituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply.
Correct Answer: A
Rationale: Post-hypophysectomy, nose blowing (A) risks CSF leak or meningitis by disrupting the surgical site. Brushing (B) and semi-Fowler's (D) are safe. Bending (C) is risky but less immediate. A is correct. Rationale: Nasal pressure can breach the pituitary fossa repair, a critical complication in early recovery, per post-operative neurosurgery care, unlike benign actions.
Question 3 of 5
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
Question 4 of 5
When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
Correct Answer: D
Rationale: When a client scheduled for surgery shows a lack of understanding and expresses concern, notifying the physician is the best action for a licensed vocational nurse. The physician, as the primary decision-maker and the one obtaining informed consent, has the responsibility to ensure the client fully comprehends the procedure, risks, and benefits. The nurse's role is to facilitate communication and advocate for the client's needs, not to independently explain complex medical details outside their scope or cancel the surgery, which exceeds their authority. Asking the supervising RN might help, but it delays direct resolution by the physician, who is legally accountable for ensuring consent is informed. This approach upholds the nurse's duty to prioritize client understanding and safety while respecting professional boundaries and legal standards.
Question 5 of 5
The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
Correct Answer: A
Rationale: Among four diagnoses, chest pain related to pneumonia takes highest priority because it addresses a physiologic need breathing and circulation per Maslow's hierarchy. Pain and potential respiratory compromise threaten survival, requiring immediate intervention like medication or oxygen. Self-care deficits, family process risks, and self-esteem issues, while important, are less urgent, impacting higher-level needs like independence or esteem. Prioritizing chest pain ensures the client's airway and oxygenation are stabilized, preventing deterioration, a fundamental principle in acute care nursing.