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 developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.
Question 2 of 5
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Fasting except for water 12 hours prior ensures a clear colon for the colonoscopy. Enemas aren't standard, clear liquids are typically 24 hours, and polyp removal occurs during the procedure.
Extract:
Nurses Notes
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 right leg upon falling. Right leg was immobilized at the scene and 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.
Vital Signs
Day 1:
Temperature 36° C (96.8° F)
Blood pressure 140/80 mm Hg
Heart rate 98/min
Respiratory rate 24/min
Oxygen saturation 97% on room air
Day 2, 0800:
Temperature 37° C (98.6° F)
Blood pressure 122/60 mm Hg
Heart rate 85/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
Question 3 of 5
The first action the nurse should take is to followed by (Postoperative tibia fixation)
Correct Answer: A,B
Rationale: Notifying the provider is urgent for complications like compartment syndrome, followed by elevation to reduce swelling.
Extract:
Question 4 of 5
A nurse is caring for a client who has hypocalcemia. For which of the following findings should the nurse monitor?
Correct Answer: A
Rationale: Tetany (muscle spasms) is a classic sign of hypocalcemia due to nerve excitability.
Question 5 of 5
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
Correct Answer: B
Rationale: Postoperative priorities follow the ABCs (Airway, Breathing, Circulation). Dark red drainage of 20 mL over 4 hours suggests potential bleeding, a circulation issue that could indicate hemorrhage a life-threatening complication after bowel resection. Pain of 6/10 is expected post-surgery and manageable with analgesics, not immediately urgent. Easy arousal with sleepiness reflects sedation or fatigue, not an acute threat unless airway compromise emerges. Urine output of 60 mL over 4 hours (15 mL/hr) is below normal (30 mL/hr), signaling oliguria, but bleeding takes precedence as it's more immediately lethal. Excessive drainage could destabilize the client faster than oliguria or pain, requiring urgent provider notification to assess for internal bleeding or anastomosis leakage. This aligns with postoperative monitoring protocols, emphasizing early detection of hemorrhage, making it the top priority to report.