ATI LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?
- A. Elevate the IV site and apply an ice pack
- B. Administer an anti-inflammatory medication
- C. Apply a cold compress to the IV site
- D. Discontinue the IV and notify the provider
Correct answer: D
Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.
2. Which nursing intervention is best for a client with constipation?
- A. Encourage the client to remain in bed to avoid straining
- B. Administer a stool softener as prescribed
- C. Increase fiber intake through dietary changes
- D. Encourage regular exercise to promote bowel movement
Correct answer: C
Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.
3. A client is having difficulty voiding after removal of an indwelling urinary catheter. What should the nurse do?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This action helps stimulate voiding post-catheterization by promoting relaxation and providing sensory input. Assessing for bladder distention after 6 hours (Choice A) is important but not the immediate intervention needed for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not effectively address the issue of post-catheterization voiding difficulty. Restricting the client's intake of oral fluids (Choice C) is not appropriate and can lead to dehydration, which is not helpful in promoting voiding.
4. A client who is newly diagnosed with iron deficiency anemia needs to include foods rich in iron in their diet. Which of the following foods should the nurse recommend as having the highest amount of iron?
- A. Boiled spinach
- B. Raw carrots
- C. Boiled chicken
- D. Yogurt
Correct answer: A
Rationale: Boiled spinach is an excellent source of iron, making it a top choice for individuals with iron deficiency anemia. Spinach contains non-heme iron, which may not be absorbed as efficiently as heme iron from animal sources but is still beneficial. Raw carrots, boiled chicken, and yogurt are not as rich in iron compared to spinach. Carrots are more known for their beta-carotene content, chicken is a good source of protein but not high in iron, and yogurt does not contain significant amounts of iron.
5. A nurse is providing discharge instructions for a client with diabetes. What is the most important teaching point?
- A. Monitor blood sugar levels weekly
- B. Administer insulin before meals as prescribed
- C. Take medication only when feeling unwell
- D. Monitor blood sugar only in the morning
Correct answer: B
Rationale: The correct answer is B: Administer insulin before meals as prescribed. This is the most important teaching point because insulin administration before meals helps manage blood sugar effectively in diabetic patients. Choice A is incorrect because monitoring blood sugar levels weekly may not provide timely information for managing diabetes. Choice C is incorrect as medications for diabetes should be taken as prescribed, not only when feeling unwell. Choice D is incorrect as blood sugar levels should be monitored at various times throughout the day, not just in the morning, to get a complete picture of the patient's condition.
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