ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
Correct Answer: C
Rationale: Recent TB exposure is the priority due to infection risk to others in a semi-private room, requiring immediate isolation precautions.
Question 2 of 5
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.
Question 3 of 5
A nurse is contributing to the plan of care for a client who is postoperative following a fasciotomy. Which of the following interventions should the nurse plan to include?
Correct Answer: C
Rationale: Post-fasciotomy care focuses on pain management, wound healing, and monitoring for complications like infection or compartment syndrome recurrence, not dietary or reproductive restrictions. Offering small, frequent meals supports nutritional needs without overloading the stomach, aiding recovery by maintaining energy for tissue repair, especially if appetite is reduced from pain or medications. A pureed diet is unnecessary unless swallowing is impaired, which isn't indicated here fasciotomy addresses limb pressure, not GI issues. Assisting to the restroom post-meals relates to bowel training, irrelevant to this surgical context. Avoiding sexual intercourse applies to pelvic procedures like colposcopy, not a limb fasciotomy. Small, frequent meals align with postoperative principles, promoting healing and comfort, making it the most relevant intervention for this client's plan of care, enhancing overall recovery without complicating the surgical focus.
Question 4 of 5
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale: Holding a cell phone on the opposite side minimizes electromagnetic interference with the pacemaker. Microwaves and airport security are generally safe, and MRIs are contraindicated due to the magnetic field.
Question 5 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.