ATI LPN
ATI PN fundamentals 2023 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Applying restraints over clothing prevents skin irritation and adds comfort, reducing risks of abrasions and pressure sores.
Question 2 of 5
A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
Question 3 of 5
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
Correct Answer: B
Rationale: Speech-language pathologists specialize in dysphagia, assessing and treating swallowing issues post-stroke.
Question 4 of 5
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.
Extract:
Nurses' Notes
Day 1:
The client is receiving intermittent tube feedings via a nasogastric tube.
Abdomen is soft, nondistended.
Head of client's bed is positioned to 30° pH of gastric aspirate 4.0
Gastric residual volume is 50 mL Day 2:
Abdomen is distended. Client reports nausea and is coughing.
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Nurses' Notes
Day 2:
Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL
pH of gastric aspirate 4.5 Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.
Choices
Nurses' Notes Day 2:
Abdomen is distended. Client reports nausea and is coughing
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
A. Distended abdomen
B. Reports nausea and coughing
C. Gastric residual volume
D. Heart rate 110/min
E. Respiratory rate 24/min
F. pH of gastric aspirate 4.5
G. Temperature 37° C (98.6° F)
Question 5 of 5
A nurse is assisting in the care of a client. Select the findings in the client's medical record that require further action by the nurse.
Correct Answer: A,B,C,D,E
Rationale: