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 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 2 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 3 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.
Question 4 of 5
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
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: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CD
C). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.