ATI LPN
LPN ATI Fundamental Exam Questions
Extract:
Question 1 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 2 of 5
A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
Question 3 of 5
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Restrict the client’s visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis may need to wear masks in certain situations. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility. Discard personal protective equipment outside the client’s room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client’s room and properly disposing of it afterward. The nurse should follow standard precautions for infection control. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
Question 4 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 5 of 5
A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?
Correct Answer: D
Rationale: A nasal cannula provides a low to moderate concentration of oxygen and is not suitable for a client experiencing severe difficulty breathing. A simple face mask provides a higher concentration of oxygen than a nasal cannula but may not deliver a high enough concentration for a client experiencing severe respiratory distress. A Venturi mask can provide a precise and adjustable concentration of oxygen but may not deliver the highest concentration needed in this scenario. A nonrebreather mask can deliver the highest concentration of oxygen (up to 100%) and is the most appropriate choice for a client experiencing severe difficulty breathing.