ATI LPN
LPN Fundamentals of Nursing
1. Prior to administering a blood transfusion, what should the healthcare professional do first?
- A. Prime the IV tubing with normal saline.
- B. Verify the client's identity.
- C. Obtain the blood product from the blood bank.
- D. Check the client's vital signs.
Correct answer: B
Rationale: Verifying the client's identity is the essential initial step before administering a blood transfusion. This action is crucial to confirm that the correct blood product is being administered to the right client, thereby preventing any potential errors or adverse reactions. Ensuring patient safety is paramount in healthcare, and verifying the client's identity is a fundamental safety measure that should always be prioritized.
2. A client with hypertension is being educated by a healthcare professional about lifestyle changes. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should consume foods low in potassium.
- B. I should consume foods low in sodium.
- C. I should consume foods high in saturated fats.
- D. I should consume foods high in cholesterol.
Correct answer: B
Rationale: The correct answer is B: 'I should consume foods low in sodium.' This statement indicates an understanding of managing hypertension. Excessive sodium intake can lead to increased blood pressure, so reducing sodium consumption is crucial in hypertension management to prevent complications. Choices A, C, and D are incorrect. Consuming foods low in potassium is not typically recommended for hypertension management as potassium-rich foods like fruits and vegetables can be beneficial. Consuming foods high in saturated fats and cholesterol can be detrimental to cardiovascular health and should be limited in individuals with hypertension.
3. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?
- A. Tremors
- B. Urine retention
- C. Kussmaul respirations
- D. Bradypnea
Correct answer: C
Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.
4. A client is being assessed for dehydration. Which of the following findings should the nurse expect?
- A. Elevated blood pressure
- B. Increased skin turgor
- C. Dark-colored urine
- D. Bradypnea
Correct answer: C
Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.
5. A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
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