ATI LPN
ATI LPN Mental Health Exam IV Questions
Extract:
Question 1 of 5
A nurse is collecting data on a patient who is postoperative following aortic valve replacement. Which of the following tasks should the nurse prioritize during data collection?
Correct Answer: A
Rationale: Pain assessment is the priority post-aortic valve replacement because it affects patient comfort, vital signs, and recovery. Unmanaged pain can increase heart rate and blood pressure, stressing the surgical site. Blood pressure, bowel sounds, and catheter site checks are important but secondary, as pain directly impacts immediate well-being and can signal complications like bleeding or infection.
Question 2 of 5
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client’s pulse, which of the following terms should the nurse use?
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to chaotic atrial impulses, disrupting ventricular rhythm. Not palpable (
B) implies no pulse, bounding (
C) suggests strength, and regular (
D) contradicts AF’s irregularity. “Irregular” accurately describes AF’s pulse quality.
Question 3 of 5
A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Checking pedal pulses every 15 minutes monitors perfusion post-femoral catheterization, detecting occlusion or bleeding. High-Fowler’s (
A) risks bleeding, ambulation (
B) is premature, and ROM (
D) disrupts site stability. Pulses ensure vascular integrity.
Question 4 of 5
A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include documenting which of the following information?
Correct Answer: A
Rationale: [Note: Document error lists A but explains hepatomegaly for right-sided failure, unrelated to BP. Assuming intent was Q32 as BP doc.] Frequency (
A) tracks trends, vital for BP management. Interventions (
B), response (
C), person (
D), and site (E) are key but secondary. A aligns with teaching focus on monitoring.
Question 5 of 5
A nurse on a telemetry unit is reviewing the laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider?
Correct Answer: B
Rationale: PT of 45 seconds (normal 11–13.5 seconds) indicates excessive anticoagulation (therapeutic 1.5–2 times normal), risking bleeding on warfarin. Hgb (16 g/dL, 13.8–17.2 g/dL), aPTT (36 seconds, 21–35 seconds), and platelets (190,000/mm, 150,000–450,000/mm) are normal. PT requires urgent reporting.