ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
47
Question 1 of 5
A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
Extract:
48
Question 2 of 5
A nurse is reinforcing bladder management instructions with a client who has urinary incontinence. Which of the following statements by the client indicates an understanding?
Correct Answer: A
Rationale: Scheduled voiding helps manage incontinence; coffee and alcohol worsen it, and self-catheterization isn't routine.
Extract:
Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
Question 3 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 report to the provider?
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
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 4 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.
Extract:
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
Question 5 of 5
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
| Findings | Acute compartment syndrome | Infection | Fat embolism syndrome |
|---|---|---|---|
| Dyspnea | |||
| Tingling sensation to right foot | |||
| Increased pain at incision site | |||
| Swelling at incision site |
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.