ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
Correct Answer: D,A,B,C,E
Rationale: The sequence is: Explain the procedure (
D) to inform the client, ensure communication (
A) during the process, remove the dressing with gloves (
B), clean the cannula (
C), and apply new ties (E). This order ensures safety and client comfort.
Question 2 of 5
A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale: Iron supplements treat anemia by boosting hemoglobin, but absorption and side effects guide administration. Option A is correct taking iron between meals maximizes absorption since food, especially calcium or fiber, can bind iron, reducing bioavailability. Gastric acid enhances uptake, so an empty stomach is ideal, though some tolerate it with a small snack if irritation occurs. Option B is wrong milk's calcium inhibits absorption and doesn't prevent teeth staining (diluting in juice does). Option C is incorrect antacids raise stomach pH, decreasing iron absorption, and may worsen deficiency. Option D is false iron typically causes black, not orange, stools due to unabsorbed iron oxidation; orange stools could signal another issue. Teaching about between-meal dosing empowers the client to optimize therapy, manage side effects (like constipation or nausea), and monitor for expected changes (e.g., darker stools), ensuring effective anemia treatment.
Question 3 of 5
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Elevating the head for 1 hour prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.
Question 4 of 5
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
Question 5 of 5
A nurse is reinforcing teaching with a client who is newly diagnosed with dumping syndrome. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D
Rationale: Dumping syndrome occurs post-gastric surgery when food moves too quickly into the small intestine, causing nausea, diarrhea, and weakness. Eliminating simple sugars is key sugars draw fluid into the gut, worsening osmotic shifts and symptoms. Remaining upright helps slow gastric emptying but isn't the primary dietary fix. Eating three large meals overloads the stomach, triggering rapid dumping, whereas small, frequent meals are recommended. Drinking water with meals dilutes stomach contents, accelerating emptying and exacerbating symptoms; fluids should be taken between meals. Cutting simple sugars (e.g., candy, soda) reduces hyperosmolarity, stabilizes digestion, and aligns with evidence-based management, improving quality of life. This instruction empowers the client to control symptoms through diet, a cornerstone of dumping syndrome care, making it the most effective teaching point.