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 at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client’s privacy?
Correct Answer: C
Rationale: Place the client’s medication record on the bedside table while ambulating the client: This action does not relate to protecting the client’s privacy. It might actually compromise confidentiality by leaving sensitive information exposed. Give a report about the client’s status while standing at the nurses’ station: This action does not protect the client’s privacy. Discussing sensitive information in a public area can lead to breaches of confidentiality. Speak with the client about their condition after visitors have left: Correct. Protecting the client’s privacy is essential, and discussing personal health information in private with the client respects their right to confidentiality. Place a message board in the client’s room to post dietary information: This action does not relate to protecting the client’s privacy. Posting dietary information may be helpful for staff, but it doesn’t address the client’s privacy concerns.
Question 3 of 5
A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?
Correct Answer: A
Rationale: Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly. Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel. Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.
Question 4 of 5
A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?
Correct Answer: C
Rationale: The client has smooth, brown, irregular lesions on the back of each hand - These are likely seborrheic keratoses, which are benign, age-related lesions and do not usually require reporting unless changes suggest malignancy. The presence of glossy, white arches around the periphery of the corneas is a normal finding, known as arcus senilis, which is commonly seen in older adults and not typically a cause for concern. The client reports urinary incontinence - Urinary incontinence can be a sign of underlying issues such as a urinary tract infection or neurological disorder, necessitating further evaluation by the provider. A decreased sense of taste is a common age-related change and may not require immediate reporting unless it is associated with other symptoms or significant nutritional issues.
Question 5 of 5
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)
Correct Answer: B, D, E
Rationale: A: A full bounding pulse is a sign of increased fluid volume or fluid overload, not fluid volume deficit. B: Cool extremities can be an indication of decreased peripheral perfusion, which may occur in fluid volume deficit. C: Moist crackles in the lungs are an indication of fluid volume excess or pulmonary congestion, not fluid volume deficit. D: Orthostatic hypotension, which is a drop in blood pressure when changing from lying to standing, can be a sign of fluid volume deficit due to inadequate blood volume. E: Flat neck veins are an indication of decreased venous return and can occur in fluid volume deficit.