ATI LPN
Medical Surgical ATI Proctored Exam Questions
Question 1 of 5
A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours, what finding would prompt the nurse to notify the health care provider immediately?
Correct Answer: B
Rationale: The correct answer is B: 60 mL of milky or cloudy drainage. This finding could indicate the presence of an infection, which is a serious complication post-neck dissection. Milky or cloudy drainage may contain pus, indicating the need for immediate intervention to prevent further complications. A: Presence of small blood clots in the drainage is relatively common and may not necessarily indicate a problem unless there are large clots or excessive bleeding. C: Spots of drainage on the dressings surrounding the drain are expected and do not necessarily warrant immediate notification unless there is excessive leakage. D: 120 mL of serosanguinous drainage is within the expected range for the first 24 hours postoperatively and may not be a cause for immediate concern unless there are other symptoms present.
Question 2 of 5
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B: Contact the primary care provider promptly and report these signs of perforation. Rationale: 1. Sudden increase in temperature, sudden onset of exquisite abdominal tenderness, and uncharacteristically rigid abdomen are signs of perforation in diverticulitis. 2. Promptly contacting the primary care provider allows for immediate evaluation and intervention. 3. Perforation is a serious complication that requires urgent medical attention to prevent further complications like sepsis. Summary of other choices: A: Administering a Fleet enema is not appropriate and can worsen the condition of a perforated diverticulum. C: Inserting an NG tube is not indicated for a perforated diverticulum and may exacerbate the situation. D: Reporting the client may be obstructed is not accurate based on the signs presented and does not address the urgency of perforation.
Question 3 of 5
When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Risk for infection related to possible rupture of the appendix. This is the priority nursing diagnosis because appendicitis can lead to a life-threatening condition if the appendix ruptures. The nurse needs to monitor for signs of worsening infection such as fever and increased pain. A: Imbalanced nutrition is not the priority as it is secondary to the risk of infection. C: Constipation is not the priority as it is not directly related to the life-threatening complication of appendicitis. D: Chronic pain is also not the priority as the risk of infection and potential rupture take precedence in the care of the patient.
Question 4 of 5
A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Report signs and symptoms of obstruction to the health care provider. The priority action in this scenario is to address the possibility of an obstruction, which could be a life-threatening complication. Reporting to the healthcare provider allows for prompt assessment and intervention to prevent further complications. A: Referring to the WOC nurse may be necessary but is not the priority when obstruction is suspected. C: Encouraging mobilization is important for overall health but not the priority in this urgent situation. D: Obtaining a swab for culture is not the priority when obstruction is suspected.
Question 5 of 5
An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?
Correct Answer: C
Rationale: The correct answer is C: Toilet the client on a frequent, scheduled basis. This intervention is appropriate for managing fecal incontinence in individuals with Alzheimer's disease. By establishing a routine for toileting, the nurse can help the client maintain continence and reduce the risk of accidents. This approach also promotes dignity and independence for the client. A: Keeping a food diary may be helpful for identifying triggers of fecal incontinence, but it is not the most immediate intervention in this case. B: Providing a bland, low-residue diet may not directly address the issue of fecal incontinence and may not be necessary if there has been no recent change in stool character. D: Securing an order for loperamide may be appropriate in some cases, but it is not the first-line intervention for managing fecal incontinence in this scenario.