ATI LPN Adult Medical Surgical 2023 II

Extract:

Question 1 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.

Order the Items

Source Container

Document in the client's electronic medical record that the specimen was sent to the laboratory.

Wipe the sample port with an alcohol wipe and let the alcohol dry.

Empty the urine into a sterile container labeled with the client identifiers.

Attach a sterile needleless syringe to the sample port and aspirate the specimen.

Clamp the catheter tubing distal to the sampling port for 15 min.

Correct Answer: E,B,D,C,A

Rationale: The correct sequence ensures sterility and accuracy: clamp to collect urine, clean the port, aspirate, transfer, and document.

Question 2 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?

A. Monitor for at least 150 mL of drainage every hour. B. Replace the unit when the drainage chamber is full. C. Clamp the tube for 30 min every 8 hr. D. Pin the tubing to the client's bed sheets.

Correct Answer: B

Rationale: Replacing the unit when full maintains system functionality and prevents complications like tension pneumothorax.

Question 3 of 5

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A. Leave the television on in the client's room. B. Apply a motion sensor mat to the client's bed. C. Raise all four side rails while the client is in bed. D. Move the overbed table away from the bed.

Correct Answer: B

Rationale: A motion sensor mat alerts staff to movement, reducing fall risk without restricting the client, which is safer for dementia patients.

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?

A. The client takes ibuprofen for headaches. B. The client consumed citrus juice 3 days before the test. C. The client has a history of breast cancer. D. The client had a hemorrhoidectomy 1 year ago.

Correct Answer: A

Rationale: Ibuprofen can cause gastrointestinal irritation or bleeding, leading to a false-positive fecal occult blood test result.

Question 5 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?

A. I will perform breast exams the day my period begins. B. I will perform breast exams every other month. C. It is common for the skin on my breasts to dimple. D. It is common for one breast to be larger than the other.

Correct Answer: D

Rationale: Asymmetry in breast size is normal, indicating the client understands typical breast variations during self-examination teaching.

ATI LPN Adult Medical Surgical 2023 II | Nurselytic

Nurselytic

ATI LPN

ATI LPN