ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Weighing before and after tracks fluid removal in peritoneal dialysis, assessing treatment effectiveness. Dialysate is warmed, diarrhea isn't a primary concern, and sterile gloves are preferred.
Extract:
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
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.
Nurses' Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Question 2 of 5
Which of the following 3 statements indicate the client understands the instructions? (Iron deficiency anemia)
Correct Answer: A,B,D
Rationale: Green leafy vegetables provide iron, black stools are a side effect, and taking it before meals enhances absorption.
Extract:
Question 3 of 5
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Late-stage Alzheimer's impairs mobility and cognition, increasing pressure ulcer risk from prolonged immobility. Turning the client every 2 hours redistributes pressure, maintains skin integrity, and aligns with evidence-based prevention (e.g., Braden Scale interventions). A mirror for reality orientation is ineffective late-stage patients lack recognition, and it may cause distress. Written instructions are useless due to severe cognitive decline; simplified, hands-on guidance is better for tasks like oral hygiene. Open-ended questions frustrate clients unable to process or respond, whereas yes/no prompts suit their capacity. Regular repositioning addresses a physical priority, prevents costly complications like infections or surgery, and supports dignity in care, making it the essential action for this vulnerable population.
Extract:
Exhibit 1 Exhibit 2 Exhibit 3
Graphic Record
Heart rate 112/min
Blood pressure 122/60 mm Hg
Temperature 38.6° C (101.5° F)
Respiratory rate 24/min
Question 4 of 5
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse to report to the provider?
Correct Answer: C
Rationale: Pneumonia, an acute respiratory infection, requires monitoring for signs of worsening condition or treatment response. The exhibit shows heart rate 112/min, blood pressure 122/60 mm Hg, temperature 38.6°C (101.5°F), and respiratory rate 24/min. Option C, temperature, is the priority 38.6°C indicates fever, a key sign of active infection or potential sepsis, especially with tachycardia (112/min) and tachypnea (24/min). This triad suggests systemic inflammatory response, needing urgent provider attention to adjust antibiotics or assess deterioration. Option A, sputum results, guides therapy but isn't immediately actionable without context. Option B, creatinine, monitors kidney function but isn't the acute priority here. Option D, WBC count, reflects infection severity but fever drives immediate concern. Elevated temperature, per triage protocols, signals potential escalation, making it the most critical to report for timely intervention.
Extract:
Question 5 of 5
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.