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Ati Lpn Comprehensive Predictor 2023 Proctored Exam
Total Questions : 160
Showing 10 questions, Sign in for more0900:
A 16-year-old client reports to the clinic with their friend. The client's friend informs the nurse that the client has not been themselves lately. Their parents and a sibling died due to injuries sustained when a tornado moved through their town 1 month ago. The client was the only survivor in their family and witnessed the death of their parents and sibling.
0910:
Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client states that they have always been afraid of thunderstorms. Client states they have been smoking marijuana for about 1 month because it helps clear their mind. Client also states they have no desire to leave the house. Client states they do attend school regularly and are on the honor roll.
0915:
- Temperature 36.7° C (98°F)
- Blood pressure 122/80 mm Hg
- Respiratory rate 20/min
- Heart rate 99/min
A nurse is assisting with the care of client in a clinic.
Based on the information in the client's medical record, which of the following findings require immediate follow-up?
Select the 4 findings that require immediate follow-up by the nurse.
1900:
Client presents to the clinic with a shoulder injury that occurred during a soccer game. Client unable to elevate or extend right arm. Client rates pain as 7 on a scale of 0 to 10. Client reports no significant past medical, surgical, or family history.
2000:
Health care provider, respiratory therapist, and RN at bedside for reduction of right shoulder. Medications administered as prescribed.
1900:
- Temperature 37° C (98.6° F)
- Heart rate 101/min
- Respiratory rate 20/min
- Blood pressure 128/85 mm Hg
- Oxygen saturation 100% on room air
2000:
- Temperature 37° C (98.6° F)
- Heart rate 85/min
- Respiratory rate 16/min
- Blood pressure 116/68 mm Hg
- Oxygen saturation 95% on 2 L/min via nasal cannula
2010:
- Temperature 37° C (98.6°F)
- Heart rate 68/min
- Respiratory rate 10/min
- Blood pressure 80/51 mm Hg
- Oxygen saturation 87% on 2 L/min via nasal cannula
1930:
Right shoulder x-ray shows shoulder dislocated. No fracture of clavicle or humerus.
2000:
Plan for moderate (conscious) sedation for right shoulder reduction.
2000:
Propofol 40 mg IV
Oxygen 2 L/min via nasal cannula
2004:
Fentanyl 100 mcg IV
2007:
Midazolam 2.5 mg IV
A nurse is assisting with the care of a client in an outpatient clinic.
Complete the following sentence by using the lists of options.
The nurse should prepare to administer
Explanation
Rationale for correct choices
• naloxone: The client demonstrates signs of opioid-induced respiratory depression, including a respiratory rate of 10/min, hypotension, and declining oxygen saturation despite supplemental oxygen. Fentanyl was administered shortly before the deterioration, making opioid reversal a priority. Naloxone rapidly reverses opioid effects and can improve respiratory drive and blood pressure.
• oxygen 10 L/min via face mask: The client’s oxygen saturation has dropped to 87% on 2 L/min via nasal cannula, indicating inadequate oxygenation. Escalating oxygen delivery with a face mask provides a higher concentration of oxygen to support ventilation while reversal agents take effect. This intervention addresses acute hypoxemia and reduces the risk of respiratory failure.
Rationale for incorrect choices
• an additional dose of fentanyl: Fentanyl is a potent opioid that can further suppress respiratory drive and worsen hypotension. The client is already showing adverse effects consistent with opioid overdose. Administering additional fentanyl would increase the risk of apnea and cardiovascular collapse.
• propranolol: Propranolol is a beta-blocker used to manage hypertension, tachycardia, or certain cardiac conditions. The client is hypotensive and bradycardic, making beta-blockade unsafe. This medication would further decrease heart rate and blood pressure.
• acetaminophen: Acetaminophen may help manage pain but does not address the client’s acute respiratory depression or hypoxia. The priority is airway and breathing stabilization rather than pain control. Delaying corrective interventions could result in rapid clinical deterioration.
• an additional dose of propofol: Propofol is a sedative-hypnotic that can cause significant respiratory depression and hypotension. The client is already experiencing these adverse effects following sedation. Additional propofol would worsen oxygenation and cardiovascular instability.
One week prior:
Client reports depression is increasing as they are unable to participate in activities they once enjoyed because of advancing multiple sclerosis. Client states getting into wheelchair is, "just too much for me."
Today:
Home health aide reported client will not permit turning or position changes. Client states, "I can only get comfortable curled on my left side. I'm not moving."
Today:
- Temperature 36.8° C (98.2° F)
- Heart rate 80/min
- Respiratory rate 20/min
- Blood pressure 116/76 mm Hg
1 week prior:
Reinforced teaching regarding the importance of getting out of bed and changing positions in bed. Client stated, "I will try."
A home care nurse is assisting with the care of a client.
The nurse is planning to focus data collection based on the general findings. Select 5 complications the client is at risk for.
A nurse is assisting in the care of a client receiving IV fluids. The nurse identifies that the IV pump has been infusing the fluids at double the rate of the prescribed order. After stopping the infusion, which of the following actions is the nurse's priority?
1130:
Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation. Client presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination by RN. Cervix 5 cm dilated, 50% effaced. O station.
The nurse is assisting with the care of the client following the insertion of an epidural.
1135:
Client reports pain as 7 on a scale of 0 to 10 scale with contractions and the pain "seems to be getting worse." Client requesting an epidural. Nitrazine test positive.
1200:
Contractions every 4 to 5 min, 45 to 60 seconds duration, 3+ intensity. Sterile vaginal examination performed by RN. Cervix 6 cm dilated, 70% effaced. O station. Epidural initiated by anesthesiologist.
1130:
- Temperature 36.4° C (97.5° F)
- Heart rate 84/min
- Respiratory rate 18/min
- BP 124/82 mm Hg
1200:
- Temperature 36.5° C (97.7° F)
- Heart rate 90/min
- Respiratory rate 18/min
- BP 128/84 mm Hg
1215:
- Temperature 37.1° C (98.8° F)
- Heart rate 86/min
- Respiratory rate 18/min
- BP 120/80 mm Hg
1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early decelerations. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability. Early decelerations.
A nurse is assisting with the care of a client who is in active labor.
For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
Explanation
• Monitor fetal heart rate: After epidural placement, continuous or frequent fetal heart rate monitoring is critical because maternal hypotension and uteroplacental perfusion changes can reduce fetal oxygenation. The presence of minimal variability requires close surveillance to detect deterioration.
• Place the client in left lateral position: Left lateral positioning improves uteroplacental blood flow by reducing compression of the inferior vena cava. This intervention supports fetal oxygenation and is appropriate when variability decreases following epidural anesthesia.
• Decrease the IV flow rate: Following an epidural, IV fluids are typically maintained or increased to prevent maternal hypotension. Reducing IV fluids can worsen hypotension and compromise placental perfusion, negatively affecting fetal status.
• Request a prescription for ephedrine: Ephedrine is indicated only if maternal hypotension develops. The client’s blood pressure remains stable, so requesting a vasopressor at this time is unnecessary and could cause hypertension and uterine vasoconstriction.
• Assist with administration of ampicillin IV: The client is group B streptococcus positive, and intrapartum antibiotic prophylaxis is required to reduce the risk of neonatal infection. Ampicillin administration during labor is a priority nursing intervention.
A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?
A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?
A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?
A nurse is reinforcing teaching with a newly licensed nurse about isolation precautions when caring for a client who has a Clostridioides difficile infection. Which of the following information should the nurse include in the teaching?
Day 1:
Admitted to medical-surgical unit following exploratory laparotomy for a ruptured appendix. Alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Abdominal dressing with small serosanguinous drainage.
Day 5:
Alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Bilateral pedal pulses 2+. Client reports feeling something "popped" at the abdominal incision after coughing. Abdominal dressing with large amount of serosanguinous drainage.
Day 1:
- Temperature 37.2° C (99° F)
- Blood pressure 128/60 mm Hg
- Heart rate 88/min
- Respiratory rate 18/min
- Oxygen saturation 96% on room air
Day 5:
- Temperature 38.2° C (100.8° F)
- Blood pressure 98/50 mm Hg
- Heart rate 110/min
- Respiratory rate 24/min
- Oxygen saturation 95% on room air
A nurse is assisting with the care of a client.
Select the 3 findings that require immediate follow-up.
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