ATI LPN
LPN Fundamentals of Nursing
1. What is a true statement about caring for a client with a nasogastric (NG) tube?
- A. The NG tube should be flushed with 30 mL of water every 4 hours.
- B. The client should be positioned in a supine position.
- C. The NG tube should be advanced 5 cm if resistance is met.
- D. The client's nasal mucosa should be inspected daily.
Correct answer: A
Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.
2. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
3. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?
- A. A Glasgow Coma Scale score of 13
- B. Clear fluid leaking from the nose
- C. Nausea and vomiting
- D. Anisocoria
Correct answer: B
Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.
4. A healthcare professional is assessing a client who has fluid volume overload. Which of the following findings should the healthcare professional expect?
- A. Hypotension.
- B. Bradycardia.
- C. Crackles in the lungs.
- D. Flat neck veins.
Correct answer: C
Rationale: Crackles in the lungs are a classic sign of fluid volume overload. When there is an excess of fluid in the lungs, it can manifest as crackling sounds upon auscultation. This finding indicates the accumulation of fluid in the alveoli and interstitial spaces of the lungs, which is a common manifestation of fluid volume overload.
5. A client has a new prescription for a potassium-sparing diuretic. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Oranges
- C. Spinach
- D. Apples
Correct answer: D
Rationale: Clients on potassium-sparing diuretics need to avoid high-potassium foods to prevent hyperkalemia. Apples are a low-potassium fruit, making them a suitable recommendation for clients on this type of diuretic. Bananas, oranges, and spinach are high-potassium foods that should be avoided by clients taking potassium-sparing diuretics to prevent complications such as hyperkalemia.
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