ATI LPN
ATI LPN Fundamentals Exam IV Questions
Extract:
Question 1 of 5
A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)
Correct Answer: A,B,C,E
Rationale: Restlessness, clenching, grimacing, and groaning are nonverbal signs of pain, while drowsiness may relate to medication or fatigue, not pain directly.
Question 2 of 5
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Counting the apical pulse for a full minute ensures accuracy, especially important for clients on cardiovascular medications that may affect heart rate or rhythm.
Question 3 of 5
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Raising the head of the bed is the immediate action to improve chest expansion, lung aeration, and breathing, addressing the low oxygen saturation of 88% most effectively as the first step.
Question 4 of 5
A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?
Correct Answer: C
Rationale: Asking the client to rate pain directly assesses the subjective effectiveness of the cold compress for pain relief.
Question 5 of 5
A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Determining living situation aids contact tracing, hand cleaner is standard unless soiled, and covering the mouth reduces TB spread; positive airflow is incorrect, negative is needed.