ATI LPN
ATI PN Adult Medical Surgical 2023 Questions
Extract:
Medical History.
Vital Signs
Nurses' Notes
Cerebrovascular accident 2 years ago Coronary artery disease
Hypertension
Question 1 of 4
A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
| Options | Anticipated | Non-essential | Contraindicated |
|---|---|---|---|
| Assist the client to the bathroom. | |||
| Initiate seizure precautions. | |||
| Record GCS every $15 \mathrm{~min}$ for the first $4 \mathrm{hr}$. | |||
| Elevate the head of the bed | |||
| Keep the client's head in midline position | |||
| Encourage the client to cough | |||
| Decrease oxygen to $1.5 \mathrm{~L} / \mathrm{min}$ via nasal cannula |
Correct Answer: A: Anticipated, B: Non-essential, C: Non-essential, D: Anticipated, E: Anticipated, F: Non-essential, G: Contraindicated
Rationale: A, D, E are anticipated to support mobility, reduce ICP, and maintain alignment post-CVA; G is contraindicated without specific oxygen needs assessed.
Extract:
Nurses' Notes
Vital Signs
Intake and Output
Postoperative day 1, 0900:
Client admitted following surgical removal of an abdominal
abscess. Client alert and oriented to person, place, and
time. Lung sounds clear bilaterally. Skin warm and dry to
touch. Capillary refill 2 seconds. Radial and pedal pulses
2+. Abdominal wound dressing dry and intact.
Question 2 of 4
A nurse on a medical-surgical unit is assisting in the care of a male client. Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.
Correct Answer: B,F,G
Rationale: Heart rate, blood pressure, and urinary output require follow-up to monitor for postoperative complications like hypovolemia.
Extract:
Nurses' Notes
Vital Signs
Diagnostic Results
Intake and Output
Postoperative day 1, 0900:
Client admitted following surgical removal of an abdominal abscess. Client alert and oriented to person, place, and time. Lung sounds clear bilaterally. Skin warm and dry to touch. Capillary refill 2 seconds. Radial and pedal pulses 2+. Abdominal wound dressing dry and intact.
Question 3 of 4
The nurse is continuing to assist in the care of the client. For each data collection finding, click to specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than 1 disease process or none at all.
| Options | Hypovolemic Shock | Pulmonary Embolism |
|---|---|---|
| Heart rate | ||
| Respiratory effort | ||
| Pain | ||
| Blood pressure | ||
| Mentation |
Correct Answer:
Rationale: At 0900, findings are normal, not indicating hypovolemic shock or pulmonary embolism.
Extract:
Nurses' Notes
Vital Signs
Laboratory Results
Diagnostic Results
Intake and Output
Postoperative day 1, 0900:
Client admitted following surgical removal of an abdominal abscess. Client alert and oriented to person, place, and time. Lung sounds clear bilaterally. Skin warm and dry to touch. Capillary refill 2 seconds. Radial and pedal pulses 2+. Abdominal wound dressing dry and intact.
Postoperative day 1, 2345:
Client is anxious and restless. Reports pain in chest. Lung sounds clear bilaterally. Respirations are rapid and shallow. Skin cool and moist. Capillary refill 4 seconds. Radial and pedal pulses 1+. Abdominal wound dressing dry and intact.
Question 4 of 4
The nurse should anticipate a provider prescription for.
Correct Answer: C,D
Rationale: Chest pain and poor perfusion suggest possible embolism or anemia; bumetanide addresses fluid overload, PRBCs treat anemia.
Extract:
Nurses' Notes
Vital Signs
Laboratory Results
Diagnostic Results
Intake and Output
Postoperative day 1, 0900:
Client admitted following surgical removal of an abdominal abscess. Client alert and oriented to person, place, and time. Lung sounds clear bilaterally. Skin warm and dry to touch. Capillary refill 2 seconds. Radial and pedal pulses 2+. Abdominal wound dressing dry and intact.
Postoperative day 1, 2345:
Client is anxious and restless. Reports pain in chest. Lung sounds clear bilaterally. Respirations are rapid and shallow. Skin cool and moist. Capillary refill 4 seconds. Radial and pedal pulses 1+. Abdominal wound dressing dry and intact.
Question 5 of 4
The nurse is continuing to assist in the care of the client. After reviewing the client's electronic medical record, which of the following actions should the nurse recommend to take? Select the 3 actions the nurse should recommend to take.
Correct Answer: A,E,F
Rationale: Frequent vital signs, additional IV access, and oxygen address deteriorating status and potential embolism.