ATI Fundamentals LPN

ATI Fundamentals LPN Related

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When recording blood pressure, the sounds which can be heard with a stethoscope placed over the artery is termed as:

  • A. Wheeze
  • B. Murmurs
  • C. Crackle sounds
  • D. Korotkoff sounds
Correct Answer: D

Rationale: Blood pressure measurement involves listening to arterial sounds via a stethoscope as the cuff deflates. These sounds, known as Korotkoff sounds, occur in five phases, starting with a tapping (systolic pressure) and fading to silence (diastolic pressure). Wheezes are respiratory sounds, murmurs relate to heart valves, and crackles indicate lung fluid none apply to blood pressure. Named after Nikolai Korotkoff, these sounds are a cornerstone of manual blood pressure assessment, ensuring accurate readings essential for diagnosing hypertension or hypotension, reflecting cardiovascular health.

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While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?

  • A. crackles
  • B. Rales
  • C. adventitious sounds
  • D. pleral friction rub
Correct Answer: C

Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.

The physician has ordered amitriptyline (Elavil) for a client with depression. The nurse should tell the client that:

  • A. The medication will produce a rapid improvement in mood
  • B. He might experience difficulty with urination
  • C. He should avoid milk products while taking the medication
  • D. The medication should be discontinued if he experiences dry mouth
Correct Answer: B

Rationale: Difficulty with urination is a common amitriptyline side effect (anticholinergic), needing monitoring mood improvement takes weeks, milk isn't restricted, and dry mouth doesn't warrant stopping. Nurses teach this, managing expectations, ensuring adherence in depression treatment.

Which of the following is NOT true about BP?

  • A. BP is dependent on blood volume, Cardiac output and peripheral resistance
  • B. BP is dependent on age and body weight
  • C. The BP on the left arm is higher than the right
  • D. BP is taken on the left arm because it is nearest to the heart
Correct Answer: C

Rationale: BP depends on blood volume, cardiac output, and peripheral resistance (A), and varies with age and weight (B), per cardiovascular physiology. The left arm isn't inherently higher (C) it's false; differences are minimal and individual. Left arm use (D) is convention, not proximity (it's not significantly closer). C's absolute claim lacks evidence, making it the untrue statement, as BP symmetry is typical unless pathology exists.

Which of the following statement best describe autonomy?

  • A. Doing good for the client
  • B. Fairness and equality
  • C. Respecting client's decision
  • D. Keeping promises
Correct Answer: C

Rationale: Autonomy is respecting client decisions (C), per ethics self-determination (e.g., refusing care). Doing good (A) is beneficence, fairness (B) justice, promises (D) fidelity. C best defines autonomy's focus, making it correct.

The nurse gave the wrong medication to Mr. Gary that lead to his cardiac arrest. This is an example of?

  • A. Malpractice
  • B. Negligence
  • C. Assault
  • D. Battery
Correct Answer: A

Rationale: Wrong medication causing cardiac arrest is malpractice (A) breach of nursing standards, per tort law. Negligence (B) is broader, assault (C) intent-based, battery (D) touch-based. A's professional error fits, making it correct.

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