ATI LPN
Medical Surgical ATI Proctored Exam Questions
Question 1 of 5
A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?
Correct Answer: D
Rationale: The correct answer is D because inadequate nutrition and reduced saliva production contribute to cavities. In acute illness, the client may not be able to consume a balanced diet, leading to nutrient deficiencies that weaken teeth. Reduced saliva flow decreases the mouth's ability to naturally clean and protect teeth. Choices A, B, and C are incorrect because hormonal changes from stress do not directly lead to acidic oral environment, systemic infections do not commonly affect teeth, and lack of fluoride from intravenous hydration is not a primary factor for dental caries.
Question 2 of 5
After a client's neck dissection surgery resulted in damage to the superior laryngeal nerve, what area of assessment should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: The client's swallowing ability. Damage to the superior laryngeal nerve can lead to swallowing difficulties, as it innervates the muscles involved in swallowing. Prioritizing assessment of swallowing ability is crucial to prevent aspiration and ensure adequate nutrition intake. Incorrect choices: B: The client's ability to speak - Damage to the superior laryngeal nerve mainly affects swallowing, not speech. C: The client's management of secretions - While important, it is secondary to swallowing assessment in this context. D: The client's airway patency - Although important, focusing on swallowing ability is more directly related to the nerve damage.
Question 3 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 4 of 5
When working with a client who has chronic constipation, what should be included in client teaching to promote normal bowel function?
Correct Answer: C
Rationale: The correct answer is C: Consume high-residue, high-fiber foods. High-fiber foods promote regular bowel movements by adding bulk to the stool, making it easier to pass. Fiber also helps in maintaining bowel health and preventing constipation. Glycerin suppositories (A) should not be used regularly as they can lead to dependence. Limiting physical activity (B) is not recommended as exercise can aid in promoting bowel peristalsis. Resisting the urge to defecate (D) can worsen constipation and lead to complications. In summary, promoting high-fiber diet is the most effective way to help manage chronic constipation.
Question 5 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.