ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
44
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.
Correct Answer:
Rationale: Clamping allows urine to collect, wiping ensures sterility, aspirating collects the sample, transferring maintains sterility, and documenting completes the process.
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 2 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 3 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.
Question 4 of 5
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A,B,D
Rationale: Expressing feelings aids coping, peer support helps adjustment, and familiar clothing boosts morale; phantom pain should be addressed, not ignored.
Question 5 of 5
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.