ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Post-fasciotomy, pain from surgical incision and prior compartment pressure is expected, making analgesia a priority to enhance comfort and mobility, aiding recovery. Antibiotics are proactive for infection, but no fever or purulent drainage (Exhibit) justifies immediate use prophylaxis may apply, not routine post-op. Fluid restriction contradicts hydration needs for healing and circulation, especially with serosanguinous drainage. Wound cultures are indicated for infection signs (e.g., redness, pus), not routine here with a dry, intact dressing. Pain management aligns with postoperative care principles unrelieved pain increases stress, delays ambulation, and risks chronicity making analgesic administration the most immediate, evidence-based action to support the client's well-being and surgical outcome.
Question 2 of 5
A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: D
Rationale: Perimenopause brings hormonal shifts, but urinary frequency stands out it may signal a UTI, bladder issue, or pelvic pathology, requiring urgent evaluation over typical symptoms. Difficulty sleeping and hot flashes stem from estrogen fluctuations, common and manageable with lifestyle changes. Vaginal dryness, also hormonal, responds to lubricants or estrogen therapy, not immediate concern. Frequency, however, risks infection or renal complications older women often present atypically (e.g., confusion), per geriatric guidelines. Using ABCs, elimination issues outrank comfort, driving prompt reporting for diagnostics (e.g., urinalysis), preventing progression, making it the priority finding.
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: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.
Question 4 of 5
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
Correct Answer: B
Rationale: Recent tuberculosis exposure is a public health priority it's contagious via airborne droplets, risking spread in a semi-private room. Immediate isolation and testing (e.g., PPD, chest X-ray) protect the client, roommate, and staff, per CDC guidelines. Anxiety disorder affects mental health but isn't acutely transmissible or life-threatening here. Migraines cause discomfort, not immediate danger, manageable with later intervention. Nocturia disrupts sleep and may signal underlying issues, but it's less urgent than infection control. TB exposure triggers rapid response respiratory isolation, contact tracing due to its morbidity (e.g., pulmonary damage) and outbreak potential, making it the top priority to address on admission.
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.
Question 5 of 5
The nurse is collecting data on the client. Which of the following findings require follow up? (Ski accident client)
Correct Answer: A,C,F,G
Rationale: Right leg swelling, weak pulses, pain, and X-ray (fracture) indicate urgent issues like compartment syndrome.