ATI LPN
ATI PN Adult Medical Surgical 2020 with NGN II Questions
Extract:
Question 1 of 5
A nurse is assisting with the care of a client who has a prescription for wrist restraints. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Ensuring one finger fits between the restraint and skin prevents excessive tightness, reducing the risk of impaired circulation or skin damage.
Question 2 of 5
A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?
Correct Answer: A
Rationale: A temperature of 39°C may indicate thyroid storm, a life-threatening complication requiring urgent intervention.
Question 3 of 5
A nurse is assisting with the care of a client who is at 38 weeks of gestation and in labor. Which of the following findings should the nurse report to the charge nurse immediately?
Correct Answer: C
Rationale: Fetal heart rate with absent variability indicates potential fetal distress, requiring immediate reporting to ensure timely intervention.
Question 4 of 5
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B
Rationale: Reporting muscle pain immediately is crucial, as it may indicate lactic acidosis, a rare but serious metformin side effect.
Question 5 of 5
A nurse is reinforcing teaching with a client who has COPD and reports shortness of breath and little appetite. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale: Limiting fluid intake during meals prevents early fullness, allowing more room for nutrient-dense foods to support appetite in COPD.