ATI LPN
ATI LPN adult medical surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
Extract:
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
Day 1, 1100:
Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.
Day 4, 1000:
Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.
Physical exam:
General: Appears more comfortable, not grimacing.
HEENT: Mucous membranes moist.
Cardiovascular: S1, S2, no murmur.
Respiratory: Bilateral breath sounds clear.
Gastrointestinal:
Mild tenderness to palpation.
Bowel sounds present and more regular, less high-pitched.
Skin: No jaundice noted, skin warm and dry.
The nurse continues to assist with the care of the client.
Question 2 of 5
The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?
Correct Answer: D,E,F
Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.
Extract:
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Question 3 of 5
Which of the following actions should the nurse assist with?
Correct Answer: C
Rationale: Reinforcing preoperative teaching is appropriate given the potential need for surgery due to suspected bowel obstruction, as indicated by symptoms.
Extract:
Question 4 of 5
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, and this statement reflects an understanding of breast self-examination teaching.
Extract:
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
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 the right leg upon falling. Right leg was immobilized at the scene and the 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 5 of 5
The nurse is collecting data on the client. Which of the following findings require follow up?
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.