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 assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CD
C). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.
Question 4 of 5
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
Correct Answer: B
Rationale: Fecal occult blood tests detect heme, but false positives arise from non-colonic bleeding. Ibuprofen, an NSAID, irritates the GI mucosa, causing microbleeds that mimic colorectal sources, a known confounder clients are advised to stop it pre-test. Citrus juice may cause false negatives (vitamin C interferes with guaiac reaction), not positives, and 3 days minimizes impact. A hemorrhoidectomy 1 year ago, healed, doesn't bleed unless recurrent, not suggested. Breast cancer doesn't affect GI bleeding unless metastatic, unlikely here. Ibuprofen's GI effect aligns with testing pitfalls (e.g., ACG guidelines), making it the likely false-positive source to identify.
Question 5 of 5
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
Correct Answer: D
Rationale: Liver biopsy risks bleeding due to vascularity, so platelets at 60,000/mm³ well below normal (150,000-400,000) signal thrombocytopenia, increasing hemorrhage risk. Normal bilirubin (1.0 mg/dL) and AST (34 units/L) reflect liver function, not clotting. Ammonia (55 mcg/dL) is normal, tied to encephalopathy, not biopsy safety. Low platelets impair hemostasis, often requiring transfusion or delay per procedural norms (e.g., AASL
D), prioritizing safety unlike normal labs, this demands provider action, making it the critical value to report.