ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 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 2 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.
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 3 of 5
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Prescription: Administer an iron supplement.
| Potential Prescription | Anticipated | Nonessential | Contraindicated |
|---|---|---|---|
| Administer an iron supplement | |||
| Collaborate with a nutritional consultant. | |||
| Place the client on a low sodium diet. | |||
| Restrict fluid Intake. |
Correct Answer:
Rationale: Low Hct, Hgb, and ferritin indicate iron deficiency anemia, making iron supplementation anticipated.
Extract:
Question 4 of 5
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
Question 5 of 5
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.