ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
Question 2 of 5
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
Correct Answer: D,A,B,C,E
Rationale: The sequence is: Explain the procedure (
D) to inform the client, ensure communication (
A) during the process, remove the dressing with gloves (
B), clean the cannula (
C), and apply new ties (E). This order ensures safety and client comfort.
Question 3 of 5
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Correct Answer: A
Rationale: Assisting to the restroom 30 minutes after meals leverages the gastrocolic reflex to promote bowel regularity. Limiting activity, fluids, or fiber would hinder continence efforts.
Extract:
VITAL SIGNS
Day 1:
TEMPERATURE 36° C (96.8° F)
BLOOD PRESSURE 140/80 mm Hg
HEART RATE 98/min
RESPIRATORY RATE 24/min
OXYGEN SATURATION 97% on room air
Day 2, 0800:
TEMPERATURE 37° C (98.6° F)
BLOOD PRESSURE 122/60 mm Hg
HEART RATE 85/min
RESPIRATORY RATE 18/min
OXYGEN SATURATION 98% on room air
Day 2, 1600:
Findings
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Acute compartment syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Infection
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Fat embolism syndrome
• Dyspnea
• Tingling sensation to right foot
• Increased pain at incision site
• Swelling at incision site
Question 4 of 5
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. Which finding is consistent with acute compartment syndrome?
Correct Answer: A, C
Rationale: Acute compartment syndrome post-ORIF arises from pressure buildup in muscle compartments, impairing perfusion. Increased pain at the incision site severe, unrelieved by analgesics, and disproportionate to the procedure is a hallmark, reflecting nerve and tissue ischemia. Dyspnea suggests fat embolism syndrome, a separate complication from marrow release, not compartment pressure. Tingling indicates nerve compression, a later sign, but pain precedes it in the 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). Swelling occurs, but pain's intensity and persistence distinguish compartment syndrome from normal postoperative edema. Early recognition of escalating pain prompts fasciotomy, preventing necrosis, making it the most consistent finding per orthopedic emergency protocols.
Extract:
Question 5 of 5
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.