ATI LPN
LPN Fundamentals of Nursing
1. Which of the following techniques should be used to insert an indwelling urinary catheter for a female client?
- A. Use sterile technique.
- B. Insert the catheter 2-3 inches into the urethra.
- C. Inflate the balloon after insertion.
- D. Lubricate the catheter tip before insertion.
Correct answer: D
Rationale: Lubricating the catheter tip before insertion is crucial for female urinary catheterization. This step helps reduce discomfort for the patient and facilitates smooth catheter insertion into the urethra. Using sterile technique maintains asepsis during the procedure, inserting the catheter 2-3 inches ensures proper placement, and inflating the balloon after insertion secures the catheter in place without causing trauma. Proper technique is fundamental for patient comfort, preventing infection, and ensuring the success of the catheterization procedure.
2. A client is being discharged with a prescription for furosemide. Which of the following instructions should be included?
- A. Avoid foods high in potassium.
- B. Monitor your weight daily.
- C. Take the medication with food.
- D. Change positions slowly.
Correct answer: D
Rationale: The correct instruction to include for a client being discharged with a prescription for furosemide is to 'Change positions slowly.' Furosemide, a diuretic, can cause dizziness and orthostatic hypotension, increasing the risk of falls. By advising the client to change positions slowly, the body can adjust to postural changes gradually, reducing the likelihood of falls and related injuries.
3. A client with a new diagnosis of COPD is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. You should increase your intake of high-calorie foods.
- B. You should decrease your intake of high-protein foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of high-fiber foods.
Correct answer: A
Rationale: The correct statement to include in the teaching for a client with a new diagnosis of COPD is that they should increase their intake of high-calorie foods. This is important to help maintain energy levels and manage weight. COPD can lead to increased energy expenditure due to the increased work of breathing, making it crucial to consume adequate calories for energy. High-calorie foods can help prevent weight loss and support overall nutritional status in COPD patients. Choice B is incorrect because high-protein foods are important for maintaining muscle mass in COPD patients. Choice C is incorrect as there is no need to avoid foods that contain lactose unless the client is lactose intolerant. Choice D is incorrect as increasing high-fiber foods may exacerbate symptoms like bloating and gas in COPD patients.
4. When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
5. 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.
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