ATI LPN
LPN ATI Fundamental Exam Questions
Extract:
Question 1 of 5
A nurse is reviewing the medical records of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess.
Correct Answer: D
Rationale: A urine specific gravity of 1.015 is within the normal range (1.005-1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal. A hematocrit level of 42% is within the normal range for adults (men: 38-50%, women: 35-45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload. A urine pH of 6.5 is within the normal range (4.5-8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess. A BUN level of 5 mg/dL is below the normal range (10-20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.
Question 2 of 5
Nurses notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling catheter in place and draining yellow urine. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200.
Correct Answer: C,D,F
Rationale: A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting. B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time. C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly. D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan. E: Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide. F: Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.
Question 3 of 5
A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: Asking the client why they are angry may come across as confrontational and defensive, potentially escalating the situation. It does not promote open communication or therapeutic rapport. Sharing personal information about diabetes running in the nurse’s family is not relevant to the client’s feelings or concerns and may not be helpful in addressing the client’s anger. Correct. Acknowledging the client’s feelings of anger and offering to sit down and talk provides an opportunity for therapeutic communication. This response demonstrates empathy and a willingness to listen and address the client’s concerns about insulin therapy. While it is true that insulin therapy can help reduce the risk of complications in type 2 diabetes, this response may come across as dismissive of the client’s feelings and concerns. It does not address the emotional aspect of the client’s anger.
Question 4 of 5
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?
Correct Answer: A
Rationale: Correct. Regular dental assessments every 6 months are recommended for all individuals, including young adults, to maintain good oral health and detect any potential issues early. Incorrect. Testicular examinations are important for young adult males, but they should be performed monthly as part of testicular self-examination, not every 5 years. Incorrect. Young adult females should have a routine physical examination annually, not every 4 years, to monitor their overall health and address any potential health concerns. Incorrect. While tuberculosis screening is essential in certain populations, such as healthcare workers or individuals at high risk of exposure, a tuberculosis skin test every 3 years is not a standard recommendation for all young adults.
Question 5 of 5
A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Standing facing the center of the bed at the client’s side allows the nurse to maintain proper body mechanics and use their body weight to assist in moving the client. Placing feet apart with the foot nearest the head of the client’s bed in front of the other foot also helps the nurse maintain stability and leverage while moving the client. Keeping knees and hips straight while bending at the waist toward the client is incorrect body mechanics and can put a strain on the nurse’s back. Encouraging the client to keep their legs straight and remain still is not appropriate. The client should be actively involved in the movement, assisting as much as possible, to ensure their safety and cooperation.