LPN ATI Fundamental Exam | Nurselytic

Correct Answer: B

Rationale: Restrict the client’s visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis may need to wear masks in certain situations. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility. Discard personal protective equipment outside the client’s room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client’s room and properly disposing of it afterward. The nurse should follow standard precautions for infection control. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.

Correct Answer: C

Rationale: Allowing the client to continue taking medications as they did at home without verifying the prescriptions can be unsafe and is not within the scope of nursing practice. Taking the medications from the client and discarding them is inappropriate. The nurse should not dispose of the client's medications without proper assessment and verification. Correct. The nurse should compare the medications the provider has prescribed with the medications the client brought from home to ensure accuracy and safety. This is a crucial step during admission to prevent errors or omissions in the medication regimen. Placing the medications in the medication cart and administering them without verification is unsafe and against best practices for medication administration.

Correct Answer: B

Rationale: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability. Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent. Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches. Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

Correct Answer: D

Rationale: Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer medications. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy. Identify the client by comparing the medication administration record with the client’s room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the 'three checks' and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.

Correct Answer: A,B,C,D

Rationale: Sequence of Actions: A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire. B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system. C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire’s progress and safeguarding other parts of the building. D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.