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 has a new prescription for a potassium-sparing diuretic. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Oranges
- C. Spinach
- D. Apples
Correct answer: D
Rationale: Clients on potassium-sparing diuretics need to avoid high-potassium foods to prevent hyperkalemia. Apples are a low-potassium fruit, making them a suitable recommendation for clients on this type of diuretic. Bananas, oranges, and spinach are high-potassium foods that should be avoided by clients taking potassium-sparing diuretics to prevent complications such as hyperkalemia.
3. A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?
- A. Selecting a 25-gauge needle
- B. Administering the injection at a 45° angle
- C. Using the ventrogluteal site for the injection
- D. Aspirating for blood return before injecting the medication
Correct answer: B
Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.
4. A client has a new diagnosis of hyperthyroidism and is being taught about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of iodine-rich foods.
- B. You should avoid foods that contain iodine.
- C. You should increase your intake of dairy products.
- D. You should avoid foods that contain gluten.
Correct answer: B
Rationale: The correct answer is B. In hyperthyroidism, it is advisable to avoid foods that contain iodine to help manage the condition and prevent complications. Excessive iodine intake can exacerbate hyperthyroidism symptoms by stimulating the thyroid gland. Therefore, the nurse should include information about avoiding iodine-rich foods in the client's dietary management teaching. Choices A, C, and D are incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism symptoms, increasing dairy products is not specific to managing hyperthyroidism, and avoiding gluten is more relevant for conditions like celiac disease, not hyperthyroidism.
5. What is a true statement about caring for a client with a nasogastric (NG) tube?
- A. The NG tube should be flushed with 30 mL of water every 4 hours.
- B. The client should be positioned in a supine position.
- C. The NG tube should be advanced 5 cm if resistance is met.
- D. The client's nasal mucosa should be inspected daily.
Correct answer: A
Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.
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