Questions 164

ATI LPN

ATI LPN Test Bank

PN Adult Medical Surgical 2023 Questions

Extract:


Question 1 of 5

A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Correct Answer: A

Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.

Extract:

History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.


Question 2 of 5

Which of the following findings require follow-up? (Client with generalized weakness, vegan diet, pale mucous membranes)

Correct Answer: B,C

Rationale: Decreased activity level and low hematocrit (24%) suggest anemia, requiring follow-up; breath sounds are clear, and other findings are less urgent.

Extract:


Question 3 of 5

A nurse is caring for a client who is 3 days postoperative following an ileostomy placement. Which of the following findings should the nurse report to the provider?

Correct Answer: A

Rationale: A retracted stoma is a complication requiring intervention; cherry red is normal, scant blood and dark green stool are expected early post-op.

Question 4 of 5

A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?

Correct Answer: B

Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.

Question 5 of 5

A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?

Correct Answer: A

Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.

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