LPN LPN
ATI PN Comprehensive Predictor 2024
1. A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?
- A. Avoid massaging the site after injection
- B. Massage the site after injection
- C. Use a circular motion to rub the site
- D. Apply a bandage after injecting
Correct answer: A
Rationale: The correct action for the nurse to take after administering an influenza virus immunization by the intradermal route is to avoid massaging the site. Massaging the site can spread the vaccine, potentially reducing its effectiveness. Rubbing the site in a circular motion or applying a bandage are not recommended actions as they can also interfere with the proper absorption of the vaccine.
2. A client with hypokalemia is commonly expected to present with which of the following findings?
- A. Muscle weakness
- B. Nausea
- C. Tingling sensation
- D. Increased thirst
Correct answer: A
Rationale: The correct answer is A: Muscle weakness. Hypokalemia is characterized by low potassium levels in the blood, which can lead to muscle weakness. This occurs because potassium is essential for proper muscle function, and a deficiency can impair muscle strength. Nausea (choice B) is not a typical finding associated with hypokalemia. Tingling sensation (choice C) is more commonly linked to issues like nerve damage or poor blood circulation, rather than hypokalemia. Increased thirst (choice D) is not a direct symptom of hypokalemia; it is more commonly seen in conditions like diabetes or dehydration.
3. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?
- A. Cross your legs at the knees
- B. Avoid bending your hip more than 90 degrees
- C. Sit with your legs elevated
- D. Avoid placing a pillow under your knees
Correct answer: B
Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.
4. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 150/80 mm Hg
- B. Swelling in the legs
- C. Persistent cough
- D. Heart rate of 72 beats per minute
Correct answer: C
Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.
5. Which dietary instruction is appropriate for a client with chronic kidney disease?
- A. Increase the intake of potassium
- B. Limit the intake of phosphorus-rich foods
- C. Encourage the intake of protein-rich foods
- D. Advise the client to increase fluid intake
Correct answer: B
Rationale: Limiting the intake of phosphorus-rich foods is appropriate for a client with chronic kidney disease. In individuals with chronic kidney disease, the kidneys cannot filter phosphorus effectively, leading to a buildup in the blood. This can result in bone and heart problems. Therefore, reducing phosphorus intake is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing potassium intake may be harmful as potassium levels can accumulate in the blood with impaired kidney function. Encouraging protein-rich foods may not be suitable as excessive protein intake can strain the kidneys. Advising to increase fluid intake should be done cautiously as individuals with chronic kidney disease may need to restrict fluids based on their stage of the disease.
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