ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
Correct Answer: D
Rationale: Using the left arm prevents trauma to the right side, reducing lymphedema risk; BP on the affected arm increases risk.
Question 2 of 5
A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: Post-bronchoscopy, nurses monitor for complications like bleeding, infection, or airway issues. Option A, sore throat, is a common, benign side effect from the scope, not requiring immediate reporting. Option B, blood pressure 110/78 mm Hg, is normal and stable, needing no action. Option C, presence of gag reflex, is reassuring it indicates airway protection is intact post-sedation, a positive sign. Option D, facial edema, is correct to report it's abnormal and could signal an allergic reaction to sedation, airway swelling, or trauma from the procedure, potentially compromising breathing. This finding demands urgent provider evaluation to rule out anaphylaxis or obstruction, aligning with airway management priorities. While sore throat and gag reflex are expected, facial edema deviates from the norm, requiring swift intervention to prevent escalation, making it the critical finding to escalate.
Question 3 of 5
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
Correct Answer: C
Rationale: AIDS, caused by HIV, requires strict infection control due to bloodborne transmission risk. Option C, bleach (typically a 1:10 dilution with water), is correct CDC guidelines recommend it for disinfecting HIV-contaminated surfaces, as it effectively inactivates the virus by denaturing proteins. Option A, isopropyl alcohol, disinfects but isn't the standard for blood spills; it evaporates quickly, potentially leaving viable pathogens. Option B, hydrogen peroxide, oxidizes but lacks evidence as a primary bloodborne pathogen disinfectant compared to bleach. Option D, chlorhexidine, excels for skin antisepsis, not environmental surfaces or blood cleanup. Bleach's broad-spectrum efficacy, affordability, and alignment with universal precautions make it the gold standard. Teaching this ensures the new nurse protects themselves and others, adhering to OSHA and hospital protocols, while reinforcing the importance of proper dilution (e.g., 1 part bleach to 9 parts water) for safety and effectiveness.
Question 4 of 5
A nurse is reviewing a client's medical history to identify risk factors for osteoporosis. The nurse should identify that which of the following findings is a risk factor for developing steps
Correct Answer: D
Rationale: Smoking increases osteoporosis risk by decreasing bone mass. The other options do not directly contribute to osteoporosis development.
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.