ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 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. The first action the nurse should take is to...
Correct Answer: A
Rationale: Post-ORIF, increased pain (Day 2, 1600) suggests compartment syndrome, a surgical emergency requiring immediate provider notification to evaluate for fasciotomy. Elevating the extremity at heart level balances perfusion without worsening pressure, unlike high elevation which reduces blood flow. Checking oxygen saturation and medicating pain address symptoms, not the cause pain here signals ischemia, not hypoxia. Assessing the incision (e.g., swelling) supports suspicion, but notification trumps delay; cold packs may mask signs. Monitoring vital signs is routine, but pain's acuity demands action over documentation. Prompt reporting aligns with the 6 Ps, prioritizing limb salvage, making it the critical first step.
Extract:
Nurses' Notes
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg Just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
Question 2 of 5
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Prescription: Open the splint
| Potential Prescription | Anticipated | Contraindicated | |
|---|---|---|---|
| Open the splint | |||
| Obtain a urinalysis | |||
| Place the client on NPO status | |||
| Place the client's right leg in a dependent position |
Correct Answer:
Rationale: Opening the splint relieves pressure in compartment syndrome.
Extract:
Question 3 of 5
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Head elevation for 1 hour reduces aspiration risk, critical for jejunostomy care. Other options are incorrect or unnecessary.
Question 4 of 5
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
Correct Answer: A
Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.
Question 5 of 5
A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.