LPN LPN
ATI PN Comprehensive Predictor 2023 with NGN
1. A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?
- A. Determine if the client is experiencing psychotic thinking
- B. Determine the client's support system
- C. Ask how the client copes with stress
- D. Assess the client's vital signs
Correct answer: A
Rationale: The priority is to determine if the client is experiencing psychotic thinking or suicidal ideation. In this situation, the nurse needs to assess if the client is having distorted thoughts or losing touch with reality, which could pose an immediate risk to the client's safety. While determining the client's support system, asking how the client copes with stress, and assessing vital signs are important aspects of care, they are not the priority when there is a concern about potential psychotic thinking or suicidal ideation.
2. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?
- A. Capillary refill of 1 second
- B. Capillary refill of 5 seconds
- C. Pitting edema
- D. Shortness of breath
Correct answer: B
Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.
3. Which intervention is most important for a client with rheumatoid arthritis?
- A. Massage inflamed joints with creams and oils
- B. Provide support to flexed joints with pillows and pads
- C. Position the client on their abdomen several times a day
- D. Assist with heat application and range of motion exercises
Correct answer: D
Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.
4. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?
- A. List of prescribed medications
- B. Potential complications to report
- C. Family contact details
- D. Dietary restrictions
Correct answer: B
Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.
5. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?
- A. Yankauer catheter
- B. Bulb syringe
- C. Suction catheter
- D. Sterile gloves
Correct answer: A
Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.
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