ATI LPN Adult Medical Surgical 2023 II

Question 1 of 5

A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?

A. Ensure the weights hang freely from the client's bed.B. Maintain 6.8 kg (15 lb) of weight for the client's skin traction.C. Loosen the ropes of the pulleys when repositioning the client in bed.D. Inspect the client's skin every 12 hr for signs of breakdown.

Correct Answer: A

Rationale: Weights must hang freely to maintain effective traction and alignment of the affected limb.

Question 2 of 5

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

A. Monitor for at least 150 mL of drainage every hour.B. Replace the unit when the drainage chamber is full.C. Clamp the tube for 30 min every 8 hr.D. Pin the tubing to the client's bed sheets.

Correct Answer: B

Rationale: Replacing the unit when full maintains system functionality and prevents complications like tension pneumothorax.

Question 3 of 5

A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?

A. Infiltration.B. Nerve damage.C. Phlebitis.D. Infection.

Correct Answer: A

Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue.

Question 4 of 5

A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?

A. The client's capillary refill is 3 seconds.B. The client's fingers are cool to the touch.C. The client reports severe itching under the cast.D. The client reports increased pain at the area of the fracture.

Correct Answer: D

Rationale: Increased pain may signal compartment syndrome, a medical emergency requiring immediate reporting.

Question 5 of 5

A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

A. Place the client in a private room with a private bathroom.B. Discard soiled wound care supplies in a trash receptacle outside the client's room.C. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.D. Administer antibiotic therapy before culturing the client's wound.

Correct Answer: A

Rationale: A private room minimizes infection spread and manages odor, benefiting both client and staff.

ATI LPN Adult Medical Surgical 2023 II | Nurselytic

Nurselytic

ATI LPN

ATI LPN