ATI LPN
PN Comprehensive Predictor 2020 Questions
Extract:
Nurses' Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."
Question 1 of 5
A nurse is caring for a newly admitted older adult client. Nurses' Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' Which of the following interventions should the nurse recommend to include in the client's plan of care? Select all that apply.
Correct Answer: B,C,D
Rationale: Asking for details about the fracture gathers information, discussing respite care supports the caregiver, and speaking privately assesses for abuse safely. Threatening reporting lacks evidence, and legal advice is outside nursing scope.
Extract:
Question 2 of 5
A nurse is caring for a client who has a prescription for ondansetron. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Ondansetron, an antiemetic, can cause constipation, requiring monitoring. It's given slowly IV, diluted in saline, and dosed as needed, not weekly.
Question 3 of 5
A nurse is assisting with the care of a client who is receiving a continuous IV infusion of normal saline. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Phlebitis (e.g., redness, pain) is a risk with IV infusions, requiring monitoring. Site changes are every 72-96 hr, heparin isn't routine, and rate depends on orders.
Question 4 of 5
A nurse is caring for a client who has a new prescription for albuterol via nebulizer. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Albuterol can cause tachycardia, a side effect to monitor. Deep breaths are needed, dosing is typically 4-6 hr, and O2 sat is checked as needed.
Question 5 of 5
A nurse is assisting with the care of a client who is postoperative following a laminectomy. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Urinary retention is a risk post-laminectomy due to spinal anesthesia or pain, requiring monitoring. Flat positioning varies, leg exercises are more frequent, and heat isn't standard.