a client with a serum albumin level of 3 gdl has a pressure ulcer what should the nurse do first
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

2. What are the key nursing interventions for a patient with a tracheostomy?

Correct answer: A

Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.

3. What is a primary symptom of left-sided heart failure?

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

4. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

Correct answer: A

Rationale: The correct answer is A: A history of gastroesophageal reflux disease. Clients with gastroesophageal reflux disease have a higher risk of aspiration during tube feeding due to the potential for reflux of stomach contents into the lungs. This increases the risk of aspiration pneumonia. Choices B, C, and D are incorrect. High osmolarity formulas may cause diarrhea but do not directly increase the risk of aspiration. Sitting in a high-Fowler's position actually reduces the risk of aspiration by promoting proper digestion and reducing the chance of regurgitation. A residual of 65 mL 1 hour postprandial is within an acceptable range and does not directly indicate a risk for aspiration.

5. An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?

Correct answer: D

Rationale: The LPN should question the assignment of replacing the PCA pump cartridge and tubing as it is outside the LPN's scope of practice. LPNs are not trained to handle tasks related to PCA pumps, which involve medication administration and monitoring that are typically within the RN's responsibilities. Assisting a postop client with an incentive spirometer (Choice A), collecting a clean catch urine specimen (Choice B), and providing nasopharyngeal suctioning for a client with pneumonia (Choice C) are all tasks that fall within the LPN's scope of practice and do not require questioning by the LPN.

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