LPN LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. What is the most appropriate intervention for a client with phlebitis at the IV site?
- A. Apply a warm compress to the site
- B. Discontinue the IV and notify the provider
- C. Increase the IV flow rate to prevent dehydration
- D. Monitor the site for signs of infection
Correct answer: B
Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.
2. What is the first step in assessing a patient with suspected stroke?
- A. Check for facial droop
- B. Assess speech clarity
- C. Perform a neurological assessment
- D. Call for emergency assistance
Correct answer: D
Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.
3. How should a healthcare professional assess a patient with fluid overload?
- A. Monitor weight and assess for edema
- B. Monitor blood pressure and auscultate lung sounds
- C. Assess for jugular venous distention
- D. Monitor oxygen saturation and check for fluid retention
Correct answer: A
Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.
4. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?
- A. Use the cane on the weaker side
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm with each step
Correct answer: C
Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.
5. A client who had a vaginal delivery 4 hours ago has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?
- A. Encourage ambulation
- B. Apply ice packs
- C. Restrict the client's fluid intake
- D. Administer stool softeners
Correct answer: B
Rationale: Correct Answer: Applying ice packs is the most appropriate intervention for a client with a fourth-degree perineal laceration. Ice packs help reduce swelling and promote comfort, aiding in the healing process. Choice A, encouraging ambulation, may not be suitable immediately after a fourth-degree laceration due to the need for rest and proper wound care. Choice C, restricting fluid intake, is not indicated and can lead to dehydration, which is not beneficial for wound healing. Choice D, administering stool softeners, may be necessary to prevent constipation and straining, but it is not the priority intervention at this time.
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