ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
Question 2 of 5
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
Correct Answer: E,D,C,A,B
Rationale: Order: Clamp (E), wipe port (
D), aspirate (
C), transfer (
A), document (
B) ensures sterility and proper procedure.
Question 3 of 5
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
Question 4 of 5
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
Correct Answer: B
Rationale: Fecal occult blood tests detect heme, but false positives arise from non-colonic bleeding. Ibuprofen, an NSAID, irritates the GI mucosa, causing microbleeds that mimic colorectal sources, a known confounder clients are advised to stop it pre-test. Citrus juice may cause false negatives (vitamin C interferes with guaiac reaction), not positives, and 3 days minimizes impact. A hemorrhoidectomy 1 year ago, healed, doesn't bleed unless recurrent, not suggested. Breast cancer doesn't affect GI bleeding unless metastatic, unlikely here. Ibuprofen's GI effect aligns with testing pitfalls (e.g., ACG guidelines), making it the likely false-positive source to identify.
Question 5 of 5
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
Correct Answer: B,A,C,E,D
Rationale: Sequence: Clamp tubing (
B) to collect urine, wipe port (
A), aspirate with syringe (
C), transfer to container (E), and document (
D) for a sterile specimen.