ATI LPN
Medical Surgical ATI Proctored Exam Questions
Question 1 of 5
What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?
Correct Answer: C
Rationale: The correct answer is C: Daily weights and measurement of abdominal girth. Portal hypertension can lead to fluid retention and ascites, causing weight gain and abdominal distension. Monitoring these parameters helps assess fluid status and effectiveness of treatment. A: Assessment of blood pressure and evaluation for headaches and visual changes is not a priority as they are not directly related to portal hypertension. B: Assessment for signs and symptoms of venous thromboembolism is not a priority in this case unless there are specific risk factors present. D: Monitoring blood glucose every 4 hours is not directly related to portal hypertension and is not a priority in this scenario.
Question 2 of 5
A healthcare professional is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the healthcare professional anticipate?
Correct Answer: D
Rationale: The correct answer is D: IV administration of octreotide. Octreotide is indicated for variceal bleeding as it reduces portal venous pressure, decreases blood flow to varices, and inhibits release of vasoactive substances. It helps control bleeding and stabilize the patient. Heparin (A) is not indicated for variceal bleeding. Albumin (B) may be used for volume resuscitation but does not address the bleeding. Vitamin K (C) is used for coagulation disorders, not variceal bleeding.
Question 3 of 5
What health promotion teaching should prioritize to prevent drug-induced hepatitis?
Correct Answer: B
Rationale: The correct answer is B because adhering to dosing recommendations of over-the-counter analgesics can help prevent drug-induced hepatitis by avoiding potential liver damage from excessive doses. Over-the-counter analgesics like acetaminophen can be hepatotoxic if taken in high amounts. Finishing all prescribed courses of antibiotics (A) is important for antibiotic resistance but does not specifically prevent drug-induced hepatitis. Ensuring safe disposal of expired medications (C) is crucial for environmental safety but does not directly prevent drug-induced hepatitis. Having pharmacists review drug regimens for potential interactions (D) is important for overall medication safety but does not specifically address the prevention of drug-induced hepatitis.
Question 4 of 5
A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
Correct Answer: C
Rationale: The correct answer is C: Stage 3. In hepatic encephalopathy, Stage 3 is characterized by severe confusion, difficulty arousing from sleep, and potential development of rigid extremities due to worsening brain function. This stage indicates significant impairment and requires immediate medical attention. Stage 1 and 2 are milder forms with less severe symptoms, while Stage 4 represents coma and severe neurological dysfunction, which is beyond the presented symptoms. Therefore, based on the client's clinical findings of confusion, difficulty arousing from sleep, and rigid extremities, Stage 3 is the most appropriate stage to document.
Question 5 of 5
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
Correct Answer: A
Rationale: The correct answer is A: Two to three soft bowel movements daily. Lactulose is a laxative commonly used to manage hepatic encephalopathy by reducing ammonia levels through promoting bowel movements. The desired outcome of this medication is to prevent the buildup of ammonia in the bloodstream, which can exacerbate hepatic encephalopathy. Soft bowel movements indicate that the medication is effectively promoting bowel motility and reducing ammonia levels. Choices B, C, and D are incorrect as lactulose is not directly associated with increasing appetite, resolving nausea and vomiting, or eliminating blood or mucus in the stool in this context.