ATI LPN
LPN Fundamentals of Nursing
1. A client with meningitis is being assessed by a healthcare provider. Which of the following findings should the provider expect?
- A. Negative Brudzinski’s sign.
- B. Flaccid neck muscles.
- C. Petechial rash.
- D. Hypoactive deep tendon reflexes.
Correct answer: C
Rationale: A petechial rash is a characteristic finding in clients with meningitis, indicating small, pinpoint hemorrhages under the skin. This rash results from the infection's impact on the blood vessels. Petechiae are important to recognize as they can help differentiate meningitis from other conditions with similar symptoms. Brudzinski’s sign, neck stiffness, and positive Kernig’s sign are more common physical exam findings in meningitis. Flaccid neck muscles and hypoactive deep tendon reflexes are not typically associated with meningitis.
2. A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.
3. A client has a new diagnosis of renal calculi, and the nurse is teaching about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of calcium-rich foods.
- B. You should decrease your intake of calcium-rich foods.
- C. You should increase your intake of sodium-rich foods.
- D. You should decrease your intake of potassium-rich foods.
Correct answer: B
Rationale: The correct answer is to decrease the intake of calcium-rich foods when managing renal calculi. Calcium can contribute to the formation of stones in the kidneys, so reducing its intake can help prevent the development of new calculi and manage existing ones.
4. A client with a new diagnosis of anemia is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. You should increase your intake of foods high in iron.
- B. You should decrease your intake of foods high in calcium.
- C. You should avoid foods that contain gluten.
- D. You should increase your intake of high-fat foods.
Correct answer: A
Rationale: The correct answer is A: 'You should increase your intake of foods high in iron.' This statement should be included in the teaching because increasing intake of foods high in iron is essential for managing anemia. Iron is a key component for producing hemoglobin, which carries oxygen in the blood. By increasing iron-rich foods like leafy greens, red meat, and fortified cereals, the client can help improve their hemoglobin levels and overall health. Choices B, C, and D are incorrect. Decreasing intake of foods high in calcium is not necessary for anemia management; avoiding foods that contain gluten is relevant for individuals with gluten sensitivity or celiac disease, not anemia; and increasing intake of high-fat foods is not recommended for managing anemia.
5. Which of the following techniques should be used to insert an indwelling urinary catheter for a female client?
- A. Use sterile technique.
- B. Insert the catheter 2-3 inches into the urethra.
- C. Inflate the balloon after insertion.
- D. Lubricate the catheter tip before insertion.
Correct answer: D
Rationale: Lubricating the catheter tip before insertion is crucial for female urinary catheterization. This step helps reduce discomfort for the patient and facilitates smooth catheter insertion into the urethra. Using sterile technique maintains asepsis during the procedure, inserting the catheter 2-3 inches ensures proper placement, and inflating the balloon after insertion secures the catheter in place without causing trauma. Proper technique is fundamental for patient comfort, preventing infection, and ensuring the success of the catheterization procedure.
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