ATI LPN
LPN Fundamentals of Nursing
1. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?
- A. Use a 25-gauge needle.
- B. Administer the injection slowly.
- C. Massage the site after the injection.
- D. Apply ice to the injection site before administration.
Correct answer: B
Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.
2. A client with a new diagnosis of type 2 diabetes mellitus is being taught about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should avoid foods that contain carbohydrates.
- B. You should decrease your intake of high-fiber foods.
- C. You should increase your intake of high-protein foods.
- D. You should monitor your carbohydrate intake.
Correct answer: D
Rationale: The correct answer is D: 'You should monitor your carbohydrate intake.' Monitoring carbohydrate intake is essential for managing blood glucose levels in clients with type 2 diabetes mellitus. By monitoring carbohydrate intake, individuals can make informed decisions about their dietary choices and better control their blood sugar levels. Avoiding foods that contain carbohydrates (choice A) is not advisable as carbohydrates are an essential nutrient that can be consumed in moderation. Decreasing intake of high-fiber foods (choice B) is not recommended as fiber is beneficial for glycemic control and overall health. Increasing intake of high-protein foods (choice C) is not the primary focus of dietary management for type 2 diabetes; while protein is important, it is more crucial to monitor carbohydrate intake for effective blood sugar management.
3. When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.
4. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will decrease my intake of potassium.
- B. I will increase my intake of vitamin K.
- C. I will decrease my intake of sodium.
- D. I will increase my intake of magnesium.
Correct answer: C
Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.
5. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30°
- B. Flush the tube with 50 mL of water every 2 hours
- C. Replace the feeding bag and tubing every 72 hours
- D. Check the client's gastric residual every 8 hours
Correct answer: A
Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.
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