ATI LPN
LPN ATI Fundamental Exam Questions
Extract:
Question 1 of 5
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?
Correct Answer: C
Rationale: Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe. Capillary refill is assessed to evaluate peripheral perfusion. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client’s allergy, not necessarily an adhesive probe. Remove polish from the client’s fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.
Question 2 of 5
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)
Correct Answer: B, D, E
Rationale: A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit. B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit. C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit. D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume. E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.
Question 3 of 5
A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?
Correct Answer: B
Rationale: Keep the conversation moving by asking about the client’s family: While engaging the client in conversation is important, this statement does not specifically address the client’s difficulty in talking about their illness. Let the client know that as their nurse, they are available and willing to listen: Correct. This response demonstrates the nurse’s willingness to provide emotional support and active listening. Encouraging the client to express their feelings and concerns about their illness is essential in promoting therapeutic communication. Ask if the client understands what to expect in the advanced stages of the illness: While discussing the client’s understanding of their illness is essential, it does not directly address their difficulty in talking to others about it. Ask the client’s visitors not to say anything about the advanced disease: This response may hinder communication and restrict the client’s opportunity to talk about their feelings and concerns with supportive visitors.
Question 4 of 5
A nurse is caring for a client who has a terminal illness and a family member asks why the client’s mouth is continually open. Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The reduced muscle tone relaxed the jaw muscles.' CORRECT. Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth. 'That happens when a person gets close to death.' INCORRECT. This automatic response is nontherapeutic and does not address the family member’s question. 'I can apply a chin strap to help hold the mouth closed.' INCORRECT. Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed.
Question 5 of 5
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?
Correct Answer: C
Rationale: Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe. Capillary refill is assessed to evaluate peripheral perfusion. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client’s allergy, not necessarily an adhesive probe. Remove polish from the client’s fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.