ATI LPN
ATI PN Comprehensive Predictor 2024
1. What is the role of the nurse in postoperative care for a patient with a hip replacement?
- A. Monitor for signs of infection and administer pain relief
- B. Ensure the patient follows a low-calcium diet
- C. Ensure the patient uses crutches to avoid pressure on the hip
- D. Monitor for signs of deep vein thrombosis
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.
2. How should a healthcare professional care for a patient with a colostomy?
- A. Empty the colostomy bag regularly
- B. Provide a high-fiber diet
- C. Monitor for signs of infection
- D. Change the colostomy bag every 3 days
Correct answer: A
Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.
3. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?
- A. Ask the client to discuss their feelings
- B. Explain the importance of the medications
- C. Document the refusal and withhold the medication
- D. Inform the client of the possible consequences of refusal
Correct answer: D
Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.
4. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?
- A. Maintain the client's bed in the lowest position
- B. Use a bed exit alarm system
- C. Assist the client with ambulation every hour
- D. Raise all 4 side rails for safety
Correct answer: B
Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.
5. A client with diabetes is experiencing hyperglycemia. What is the nurse's priority?
- A. Administer insulin
- B. Encourage the client to exercise to lower blood glucose
- C. Encourage the client to drink water
- D. Administer glucagon
Correct answer: A
Rationale: The correct answer is to administer insulin. In hyperglycemia, there is an excess of glucose in the blood, which needs to be lowered. Insulin is the primary medication used to lower blood glucose levels by facilitating the uptake of glucose into cells. Encouraging the client to exercise may further increase blood glucose levels due to the release of stress hormones, so it is not the priority. While staying hydrated is important, it will not directly address the high blood glucose levels seen in hyperglycemia. Glucagon is used to treat severe hypoglycemia, not hyperglycemia, so it is not the priority in this situation.
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