ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
Question 2 of 5
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.
Question 3 of 5
A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
Correct Answer: C
Rationale: Edema, coolness, and tenderness suggest infiltration, where IV fluid leaks into surrounding tissue. Infection involves warmth/redness, phlebitis includes inflammation, and nerve damage affects sensation/movement.
Question 4 of 5
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
Correct Answer: B,A,C,E,D
Rationale: Sequence: Clamp tubing (
B) to collect urine, wipe port (
A), aspirate with syringe (
C), transfer to container (E), and document (
D) for a sterile specimen.
Question 5 of 5
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.