ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
Correct Answer: B
Rationale: Postoperative priorities follow the ABCs (Airway, Breathing, Circulation). Dark red drainage of 20 mL over 4 hours suggests potential bleeding, a circulation issue that could indicate hemorrhage a life-threatening complication after bowel resection. Pain of 6/10 is expected post-surgery and manageable with analgesics, not immediately urgent. Easy arousal with sleepiness reflects sedation or fatigue, not an acute threat unless airway compromise emerges. Urine output of 60 mL over 4 hours (15 mL/hr) is below normal (30 mL/hr), signaling oliguria, but bleeding takes precedence as it's more immediately lethal. Excessive drainage could destabilize the client faster than oliguria or pain, requiring urgent provider notification to assess for internal bleeding or anastomosis leakage. This aligns with postoperative monitoring protocols, emphasizing early detection of hemorrhage, making it the top priority to report.
Question 2 of 5
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?
Correct Answer: B
Rationale: Colorectal cancer risk factors are well-documented, with family history being a major non-modifiable contributor due to genetic predisposition (e.g., Lynch syndrome). Physical inactivity increases risk by slowing bowel motility, allowing carcinogen exposure, but it's less definitive than genetics. A high-fiber diet reduces risk by promoting regular bowel movements, not increasing it, so it's incorrect here. Age over 50 is a strong risk factor as incidence rises with age, but family history often trumps it in teaching specificity due to its hereditary link. Emphasizing family history educates the client on screening needs (e.g., earlier colonoscopy), aligning with guidelines like those from the American Cancer Society. It's a critical, actionable factor, driving personalized prevention and surveillance, making it a standout choice for inclusion in teaching.
Question 3 of 5
A nurse is collecting data from a client who has heart failure. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: Heart failure management hinges on detecting decompensation, where weight gain from fluid retention is a red flag. Sudden increases (e.g., 2-3 lbs overnight) signal worsening congestion, necessitating prompt provider action like diuretic adjustment. Activity tolerance reflects functional status but is subjective and less urgent unless acutely dropping. Chest x-ray results show pulmonary edema or cardiomegaly, but weight offers earlier, actionable data. Echocardiogram results assess heart function long-term, not immediate changes. Daily weight monitoring is a cornerstone of heart failure care fluid overload precedes symptoms like dyspnea, making it the priority to report. This aligns with clinical guidelines (e.g., ACC/AH
A), enabling timely intervention to prevent hospitalization or acute failure, emphasizing its critical role in ongoing assessment.
Question 4 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 involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
Question 5 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: Closed-chest tube systems manage pleural fluid or air, requiring patency and safety. Replacing the unit when the drainage chamber is full maintains system function overflow risks backpressure or infection, per manufacturer guidelines. Monitoring for 150 mL/hr is excessive; normal drainage tapers post-insertion, and sudden high output signals bleeding, not a routine action. Clamping the tube risks tension pneumothorax by trapping air or fluid, only done briefly under specific orders (e.g., checking for leaks). Pinning tubing to sheets prevents dislodgement but isn't the primary maintenance action. Full chamber replacement ensures continuous drainage, aligns with infection control (e.g., CDC standards), and prevents complications like lung collapse, making it the nurse's key responsibility in chest tube care.