ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 5
A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?
Correct Answer: C
Rationale: The correct answer is C: Keep the ulcer clean and dry. This instruction is essential for promoting healing of the foot ulcer in a client with type 2 diabetes mellitus. Keeping the ulcer clean helps prevent infection, while keeping it dry promotes a better environment for healing. A: Applying a heating pad can increase the risk of burns and should be avoided. B: Wearing tight-fitting shoes can cause further damage and hinder healing. D: Limiting walking may reduce pressure on the ulcer, but mobility is important for circulation and overall health. Keeping the ulcer clean and dry is the most critical instruction.
Question 2 of 5
A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider. A prolonged aPTT of 90 seconds indicates the client is at risk for bleeding due to excessive anticoagulation from heparin therapy. The nurse should notify the healthcare provider immediately to adjust the dosage or consider discontinuing heparin to prevent bleeding complications. Increasing the heparin infusion rate (A) would worsen the risk of bleeding. Applying pressure to the injection site (C) is not appropriate in this situation. Administering protamine sulfate (D) is the antidote for heparin overdose, but it is not the first action to take in this scenario.
Question 3 of 5
The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?
Correct Answer: A
Rationale: The correct answer is A: Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber indicates an air leak in the system, which can lead to pneumothorax or compromised lung function. Immediate intervention is required to prevent complications. Serosanguineous drainage in the collection chamber (B) is expected after thoracotomy. Intermittent bubbling in the suction control chamber (C) is normal and indicates proper suction function. Chest tube secured to the client's chest wall (D) is essential for stability and should not require immediate intervention.
Question 4 of 5
A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?
Correct Answer: B
Rationale: Correct Answer: B - Take calcium supplements with meals. Rationale: 1. Calcium is essential for bone health and helps prevent osteoporosis. 2. Taking calcium with meals enhances absorption. 3. Adequate calcium intake is crucial for individuals with osteoporosis. Summary: A: Avoiding weight-bearing exercises is incorrect as they are beneficial for bone health. C: Limiting vitamin D intake is incorrect as it is needed for calcium absorption. D: Increasing caffeine intake is incorrect as it can decrease calcium absorption and worsen osteoporosis.
Question 5 of 5
A client with chronic kidney disease (CKD) is experiencing hyperkalemia. Which intervention should the nurse implement to address this condition?
Correct Answer: A
Rationale: The correct answer is A: Administer calcium gluconate. Calcium gluconate is used to stabilize the cardiac membrane in hyperkalemia, preventing dangerous cardiac arrhythmias. It does not lower potassium levels but helps protect the heart. B: Encouraging a diet high in potassium would worsen hyperkalemia. C: Providing potassium supplements would further elevate potassium levels. D: Restricting sodium intake does not directly address hyperkalemia.