ATI LPN
Medical Surgical ATI Proctored Exam Questions
Question 1 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 2 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 3 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 4 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 5 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.