ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
Correct Answer: C
Rationale: Grab bars enhance safety and independence in the shower post-CVA. Fatigue is possible, full assistance isn't always needed, and a towel could be a slip hazard.
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.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
Question 2 of 5
Which of the following actions should the nurse take? (Post-fasciotomy)
Correct Answer: A,B,D
Rationale: Antibiotics prevent infection, analgesics manage pain, and a wound culture assesses for infection post-fasciotomy.
Extract:
Question 3 of 5
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
Correct Answer: A,B,C,D,E
Rationale:
Steps are: Cleanse (
A), dry (
B), pierce (
C), squeeze (
D), and apply (E), ensuring a clean and accurate glucose reading.
Question 4 of 5
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
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: Replacing the unit when full maintains system function. Clamping risks tension pneumothorax, pinning can dislodge tubing, and 150 mL/hr is excessive and not a standard expectation.