LPN LPN
ATI PN Comprehensive Predictor 2023
1. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?
- A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
- B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
- C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
- D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL
Correct answer: B
Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.
2. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
- A. Cancer of any type
- B. Impaired hearing
- C. Prescription drug intoxication
- D. Heart failure
Correct answer: C
Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium in older adults is commonly caused by medication side effects or interactions. Investigating prescription drug intoxication is crucial as it can be a reversible cause of delirium. While cancer, impaired hearing, and heart failure are important considerations in overall care, prescription drug intoxication takes precedence in cases of delirium.
3. A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?
- A. Inject insulin into the muscle
- B. Rotate injection sites with each dose
- C. Store insulin at room temperature
- D. Massage the injection site after administration
Correct answer: B
Rationale: The correct instruction that the nurse should include is to rotate injection sites with each dose. This practice is essential to prevent tissue damage and ensure proper insulin absorption. Option A is incorrect because insulin should not be injected into the muscle, but rather into the subcutaneous tissue. Option C is incorrect as insulin should be stored in the refrigerator to maintain its effectiveness. Option D is incorrect as massaging the injection site after administration can lead to faster absorption and potentially hypoglycemia.
4. How should a healthcare professional assess and manage a patient with a tracheostomy?
- A. Monitor for signs of infection and ensure airway patency
- B. Suction airway secretions and provide humidified air
- C. Inspect stoma site and clean with saline
- D. Provide education on tracheostomy care
Correct answer: A
Rationale: Correct answer: Monitoring for signs of infection and ensuring airway patency is crucial in managing a patient with a tracheostomy. This involves observing for redness, swelling, or discharge at the stoma site, as well as assessing for any signs of respiratory distress. Choice B, suctioning airway secretions and providing humidified air, is important for maintaining airway hygiene but may not be the initial assessment priority. Choice C, inspecting the stoma site and cleaning with saline, is part of routine tracheostomy care but does not address immediate assessment and management needs. Choice D, providing education on tracheostomy care, is valuable but not the primary action required in the assessment and management of a patient with a tracheostomy.
5. What are the nursing interventions for a patient with a pressure ulcer?
- A. Clean the wound and apply a hydrocolloid dressing
- B. Provide a high-protein diet and ensure bed rest
- C. Monitor for signs of infection and provide antibiotics
- D. Provide a low-sodium diet and monitor for fluid retention
Correct answer: A
Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.
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