ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 5
The nurse is planning care for a client with cirrhosis of the liver. Which intervention should the nurse include to reduce the risk of bleeding?
Correct Answer: C
Rationale: Correct Answer: C - Administer vitamin K as prescribed. Rationale: 1. Cirrhosis impairs liver function, leading to decreased synthesis of clotting factors, increasing the risk of bleeding. 2. Vitamin K is essential for synthesizing clotting factors; administering it helps improve clotting ability. 3. Monitoring for infection (A) is important but does not directly address the clotting issue. 4. Limiting protein intake (B) is not necessary for bleeding prevention in cirrhosis. 5. Encouraging fluid intake (D) is important for overall health but does not specifically reduce the risk of bleeding.
Question 2 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 3 of 5
The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding should the provider expect?
Correct Answer: A
Rationale: The correct answer is A: Increased anteroposterior chest diameter. In COPD, the chronic airway obstruction leads to air trapping, causing the chest to become hyperinflated. This results in an increase in the anteroposterior chest diameter, often referred to as "barrel chest." Explanation for why other choices are incorrect: B: Decreased respiratory rate is not typically seen in COPD; patients often exhibit an increased respiratory rate due to difficulty breathing. C: Dull percussion sounds over the lungs are associated with conditions like pneumonia or pleural effusion, not COPD. D: Hyperresonance on chest percussion is typically found in conditions like emphysema, a type of COPD, but it is not specific to COPD as a whole.
Question 4 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 5 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.