ATI LPN
LPN ATI Fundamental Exam Questions
Extract:
Question 1 of 5
A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
Correct Answer: B
Rationale: Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick release ties to ensure safety. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client’s comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick release ties to allow for easy removal in emergencies.
Question 2 of 5
A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: I will be sure to keep the crutch tips dry.' While it is important to keep the crutch tips dry to maintain traction and stability, this statement does not specifically address the correct technique for going up stairs with crutches. 'I will hold a crutch in each hand when sitting down.' This statement does not address the correct technique for going up stairs with crutches. However, it is a correct statement regarding sitting down with crutches. 'I will place my weight on my underarms.' Placing weight on the underarms is an incorrect crutch-walking technique. It can lead to nerve compression and injury. Instead, the client should bear weight on their hands and palms when using crutches. 'I will lead with my right leg when going upstairs.' Correct. When going up stairs with crutches, the client should lead with their unaffected leg (in this case, the right leg) first. The crutches are then advanced, one at a time, to the same step. This sequence ensures better stability and safety during stair climbing with crutches.
Question 3 of 5
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of her behavior change?
Correct Answer: A
Rationale: Precontemplation: According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action, and the maintenance stage. Preparation: INCORRECT. The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage.
Question 4 of 5
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
Correct Answer: B
Rationale: Check the capillary refill every 4 hrs: Incorrect. The nurse should check capillary refill distally every 4 hr for a client who has elastic bandages on their lower extremities. Compare the pedal pulses every 4 hrs: CORRECT. The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their lower extremities.
Question 5 of 5
A nurse is caring for a client who has a terminal illness and a family member asks why the client’s mouth is continually open. Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The reduced muscle tone relaxed the jaw muscles.' CORRECT. Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth. 'That happens when a person gets close to death.' INCORRECT. This automatic response is nontherapeutic and does not address the family member’s question. 'I can apply a chin strap to help hold the mouth closed.' INCORRECT. Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed.