ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: Six small meals reduce stomach pressure and reflux in GERD. Orange juice can worsen reflux, lying down post-meal increases it, and sleeping flat doesn't help.
Question 2 of 5
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
Correct Answer: B
Rationale: Transfer documentation ensures continuity of care, focusing on critical, current data for the receiving team. The primary health problem is essential it summarizes why the client's status changed (e.g., respiratory failure, sepsis), guiding ICU interventions. Number of family members who visited is irrelevant to clinical management; it's a social detail, not a priority. Admission vital signs from a week ago are outdated current vitals matter more, especially with a status change. Scheduled dressing changes are useful but secondary to understanding the underlying condition driving the transfer. Identifying the primary issue provides context for the client's deterioration, aligns with handoff standards like SBAR (Situation, Background, Assessment, Recommendation), and ensures the ICU team addresses the root cause immediately. This focus on relevance enhances patient safety, reduces miscommunication, and supports rapid response in a critical setting, making it the most vital piece of transfer information.
Question 3 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 support balance and safety, key for CVA clients with ADL challenges. Other options are impractical or unsafe.
Question 4 of 5
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Easy bruising is expected in Cushing's syndrome due to excess cortisol thinning the skin and weakening blood vessels. Jaundice, rigidity, and weight loss are not typical.
Question 5 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.