LPN LPN
ATI PN Comprehensive Predictor 2020
1. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: B
Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.
2. How should a healthcare provider assess a patient with sepsis?
- A. Monitor vital signs and administer fluids
- B. Monitor for fever and administer antibiotics
- C. Check for tachycardia and elevated white blood cell count
- D. Administer fluids and provide nutritional support
Correct answer: A
Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.
3. A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?
- A. Apply moisturizing lotion to the skin
- B. Turn off the lights
- C. Remove all jewelry
- D. Gently close the client's eyelids
Correct answer: D
Rationale: The correct action the nurse should take is to gently close the client's eyelids. This is a respectful and common practice in postmortem care before allowing the family to view the body. Applying moisturizing lotion to the skin is unnecessary and may not be appropriate at this time. Turning off the lights might not be necessary and could impact the viewing environment for the family. While removing all jewelry is generally a good practice, it is not as crucial as gently closing the client's eyelids for postmortem care.
4. What is the most important action when providing wound care to a client with a pressure ulcer?
- A. Apply a dry, sterile dressing to the wound
- B. Cleanse the wound with normal saline
- C. Perform a wound culture before applying ointment
- D. Cover the wound with a wet-to-dry dressing
Correct answer: C
Rationale: Performing a wound culture before applying ointment is crucial when providing wound care to a client with a pressure ulcer. This action helps identify any underlying infections, allowing healthcare providers to select the most appropriate treatment. Options A, B, and D are not as critical as performing a wound culture, as they focus on wound dressing and cleansing rather than identifying potential infections.
5. When caring for a client with a wound infection, what is the most important nursing action?
- A. Change the dressing every 4 hours
- B. Perform a wound culture before administering antibiotics
- C. Cleanse the wound with alcohol-based solutions
- D. Apply a wet-to-dry dressing to the wound
Correct answer: B
Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.
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