ATI LPN
LPN Fundamentals of Nursing Test Questions
Question 1 of 5
The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is $89 \%$. Which action should the nurse implement?
Correct Answer: C
Rationale: An oxygen saturation of $89% during suctioning indicates hypoxia; stopping the procedure (C) is the priority to restore oxygenation. Continuing (A) worsens desaturation. Calling respiratory (B) or changing catheters (D) delays action. C is correct. Rationale: Ceasing suctioning allows reoxygenation, preventing further decline, a critical step per oxygenation management guidelines, prioritizing patient stability.
Question 2 of 5
A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?
Correct Answer: C
Rationale: In the immediate post-SCI period, avoiding spine flexion or hyperextension (C) prevents further damage. UTIs (A) and contractures (B) are later concerns. Rehabilitation (D) is long-term. C is correct. Rationale: Spine stabilization is critical to limit cord injury progression, a priority in acute SCI management, per trauma protocols, ensuring neurological preservation over secondary or chronic care goals.
Question 3 of 5
The nurse is caring for a client who is tetraplegic following a diving accident and is experiencing autonomic dysreflexia due to a blocked urinary catheter. Which immediate nursing action is appropriate?
Correct Answer: B
Rationale: Autonomic dysreflexia in tetraplegia from a blocked catheter requires removing the stimulus (B), e.g., unblocking the catheter, to halt the sympathetic surge causing hypertension. Medication (A) or elevation (C) treats symptoms, not the cause. Notification (D) follows. B is correct. Rationale: Relieving the trigger (catheter obstruction) stops the reflex, a priority per SCI emergency protocols, preventing stroke or seizure, unlike secondary symptomatic management.
Question 4 of 5
The nurse is assessing a client with a traumatic brain injury who has a ventriculostomy in place. Which finding indicates a complication that requires immediate reporting?
Correct Answer: D
Rationale: Yellowish drainage (D) from a ventriculostomy suggests infection (e.g., meningitis), needing immediate reporting. Clear fluid (A) is normal CSF. ICP 18 (B) is borderline. Fever (C) is nonspecific. D is correct. Rationale: Infection risks brain damage, requiring antibiotics, per neurosurgical care, a critical complication.
Question 5 of 5
The physician writes an order for 'progressive ambulation, as tolerated.' The RN writes an order for 'Dangle for 5 min. 12 h post op and stand at bedside 24 h post op.' The LVN assigned to care for this client should do which of the following?
Correct Answer: C
Rationale: For an LVN following orders for progressive ambulation, checking vital signs before dangling or standing is essential to ensure client safety. Post-operative clients may experience instability like low blood pressure making assessment critical before activity. Calling the physician or State Board is unnecessary unless orders conflict, and client agreement alone doesn't guarantee safety. This action aligns with the LVN's role in monitoring and implementing care, preventing complications like syncope while adhering to the RN's specific directives.