LPN LPN
ATI PN Comprehensive Predictor 2020
1. When should a nurse suction a client with a tracheostomy?
- A. Every 6 hours, regardless of distress signs
- B. When the client's respiratory rate drops below 10
- C. When the client shows signs of irritability
- D. When the client begins to cough or show signs of airway blockage
Correct answer: C
Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.
2. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?
- A. Heart rate 56/min.
- B. Oxygen saturation 93%.
- C. Respiratory rate 18/min.
- D. Blood pressure 118/74 mm Hg.
Correct answer: A
Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.
3. How should a healthcare provider respond to a patient experiencing a seizure?
- A. Protect the airway and monitor for post-ictal confusion
- B. Administer anticonvulsant medications
- C. Apply restraints to prevent injury
- D. Place the patient in a side-lying position
Correct answer: D
Rationale: When a patient is experiencing a seizure, the immediate priority is to ensure their safety by placing them in a side-lying position. This helps prevent aspiration in case of vomiting and maintains an open airway. Administering anticonvulsant medications is not within the scope of a healthcare provider's immediate response during a seizure. Applying restraints can potentially harm the patient by restricting movement and causing injury. Monitoring for post-ictal confusion is important after the seizure has ended, but the primary concern during the seizure is ensuring the patient's safety.
4. A healthcare professional is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer?
- A. Family history of asthma
- B. Elevated BMI
- C. History of travel
- D. High cholesterol
Correct answer: B
Rationale: Elevated BMI is a significant risk factor for colorectal cancer. Excess body weight, especially around the waist, increases the risk of developing this type of cancer. Family history of asthma (Choice A) is not directly related to colorectal cancer risk. History of travel (Choice C) and high cholesterol (Choice D) are also not established risk factors for colorectal cancer.
5. What are the nursing interventions for a patient with fluid volume overload?
- A. Restrict fluid intake
- B. Monitor intake and output
- C. Administer diuretics as prescribed
- D. Elevate the head of the bed
Correct answer: A
Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.
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