ATI LPN
ATI LPN Med Surg Level 3 II Questions
Question 1 of 5
A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?
Correct Answer: D
Rationale: The background component of SBAR provides relevant medical history. The client's history of hypertension is pertinent to the current situation and should be included in the background. The other options belong to different SBAR components: A (recommendation), B (assessment), and C (situation).
Question 2 of 5
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: Smoking, obesity, hypertension, and hypercholesterolemia can be modified through lifestyle changes or medication, reducing atherosclerosis risk. Genetic predisposition is non-modifiable.
Question 3 of 5
A nurse in a provider's office is reinforcing teaching with a client who has risk factors for atherosclerosis. The nurse should help the client identify which of the following as treatment goals?
Correct Answer: B
Rationale: Maintaining blood pressure below 140/90 mm Hg is a realistic goal to reduce vascular damage in atherosclerosis. Cholesterol should be <200 mg/dL, fat intake should be 25-35% of calories, and BMI should be in the healthy range (18.5-24.9).
Extract:
Medical History
Client has a history of left-sided heart failure, hypertension, chronic atrial fibrillation with controlled rate, coronary artery disease (coronary bypass surgery 5 years ago).
Client was admitted to hospital directly from provider office visit. Reports increasing weakness and shortness of breath with minimal exertion.
Diagnostic Results
Basic Metabolic Profile (BMP):
Glucose 148 mg/dL (200 mg/dL)
BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.94 mg/dL (0.05 to 1.3 mg/dL)
Sodium 142 mEq/L (136 to 145 mEq/L)
Potassium 4.4 mEq/L (3.5 to 5 mEq/L)
Chloride 100 mEq/L (98 to 106 mEq/L)
Calcium 9.6 mg/dL (9 to 10.5 mg/dL)
Phosphorus 4,2 mg/dL (3 to 4.5 mg/dL)
Cardiac Enzyme Laboratory Report:
TROPONIN T 0.06 ng/mL (less than 0.1 ng/mL)
TROPONIN 10.1 ng/mL (less than 0.3 ng/mL)
B-natriuretic peptide (BNP) 800 ng/mL (less than 100 ng/mL)
ECG Report: Atrial fibrillation, rate 135/min
Chest x-ray Report: Cardiomegaly with bilateral pleural chest effusions indicative of heart failure.
Nurses Notes
Physical Assessment:
Neurological: Client is alert, oriented x 3. Follows simple commands, responds to questions appropriately, moves all extremities well.
Cardiac: Heart rate is elevated at 138 beats/min, irregular rhythm. Pulses to lower extremities irregular and weak. Telemetry monitor showing atrial fib with rapid ventricular response (RVR). Client denies chest pain or discomfort.
Respiratory: Respirations at 28/min, O2 saturation 93% on 2 L via nasal cannula. Frequent cough noted with pink-tinged sputum. Client denies shortness of breath at this time.
Gastrointestinal: Bowel sounds active x 4 quadrants. States last bowel movement this morning with no irregularities.
Genitourinary: States no problems voiding. Urine clear, yellow.
Vital Signs
Temperature 37.2° C (98.9° F)
Heart rate 138/min
Respiratory rate 28/min
Blood pressure 96/75 mm Hg
O2 saturation 93% on 2 L/min via nasal cannula
Question 4 of 5
A nurse is assisting with the admission of a client who has a history of heart failure. Which of the following findings require immediate follow-up by the nurse? Select all that apply.
Correct Answer: B,D,E,F,G
Rationale: Vital signs (elevated heart and respiratory rates, low BP) indicate instability. Elevated troponin (10.1 ng/mL) suggests myocardial injury. High BNP (800 ng/mL) confirms worsening heart failure. Respiratory findings (pink-tinged sputum, high respiratory rate) suggest pulmonary congestion. ECG showing atrial fibrillation with RVR (135/min) requires rate control to prevent complications.
Extract:
Question 5 of 5
A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)
Correct Answer: A,C
Rationale: Monitoring blood pressure ensures lisinopril efficacy. A persistent dry cough is a common side effect requiring reporting. Cholesterol monitoring is not routine for lisinopril, and excessive potassium intake should be avoided due to hyperkalemia risk.