ATI LPN
ATI PN Comprehensive Predictor 2020
1. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?
- A. Encourage the client to eat high-protein foods
- B. Encourage the client to drink 2 liters of fluid daily
- C. Instruct the client to use a soft toothbrush
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: C
Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.
2. Which of the following is an early indication that a tracheostomy client requires suctioning?
- A. Bradycardia
- B. Irritability
- C. Hypotension
- D. Decreased respiratory rate
Correct answer: B
Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.
3. A nurse is teaching a client who has irritable bowel syndrome (IBS) about dietary modifications. Which of the following instructions should the nurse include?
- A. Increase fiber intake to 35 grams per day
- B. Avoid dairy products
- C. Eat small, frequent meals
- D. Avoid fruits and vegetables
Correct answer: C
Rationale: The correct answer is C: 'Eat small, frequent meals.' Eating small, frequent meals helps manage IBS symptoms by avoiding overloading the digestive system. Choice A is incorrect because increasing fiber intake may worsen symptoms in some individuals with IBS. Choice B is not a blanket recommendation for all IBS patients; some may tolerate dairy products well. Choice D is incorrect as fruits and vegetables are important sources of nutrients and should not be completely avoided unless specific triggers are identified.
4. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?
- A. Document the client's status every 60 minutes.
- B. Provide a staff member to stay with the client continuously.
- C. Measure vital signs every 4 hours.
- D. Obtain a prescription for the restraints every 8 hours.
Correct answer: B
Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.
5. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?
- A. Client reports nausea.
- B. Urinary output of 20 mL/hr.
- C. Oxygen saturation 90%.
- D. Respiratory rate 14/min.
Correct answer: C
Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.
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