ATI LPN
ATI LPN Fundamentals Exam II Questions
Extract:
A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot
Question 1 of 5
A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot. What action should the nurse take?
Correct Answer: B
Rationale: Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Extract:
A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing
Question 2 of 5
A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. What is the nurse's priority action?
Correct Answer: D
Rationale: Evaluating the client's respiratory status is the priority action. The nurse should assess the client's breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client's difficulty breathing and guide further interventions.
Extract:
Upon inspecting a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum
Question 3 of 5
Upon inspecting a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?
Correct Answer: C
Rationale: A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying muscle or bone.
Extract:
A nurse is caring for a client whose hand movement is limited
Question 4 of 5
A nurse is caring for a client whose hand movement is limited. What action should the nurse take to assist the client with feeding?
Correct Answer: A
Rationale: Providing an adaptive feeding device, such as a built-up utensil or a swivel spoon, can help clients with limited hand movement feed themselves independently. These devices are designed to make grasping and manipulating utensils easier, promoting independence and self-care.
Extract:
A nurse is preparing to administer vitamin K intramuscularly to a newborn
Question 5 of 5
A nurse is preparing to administer vitamin K intramuscularly to a newborn. Which of the following muscles should the nurse use for the injection?
Correct Answer: D
Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in newborns. It is the most developed muscle in this age group and is free of major nerves and blood vessels.