ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Question 1 of 5
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
Correct Answer: D
Rationale: Liver biopsy risks bleeding due to vascularity, so platelets at 60,000/mm³ well below normal (150,000-400,000) signal thrombocytopenia, increasing hemorrhage risk. Normal bilirubin (1.0 mg/dL) and AST (34 units/L) reflect liver function, not clotting. Ammonia (55 mcg/dL) is normal, tied to encephalopathy, not biopsy safety. Low platelets impair hemostasis, often requiring transfusion or delay per procedural norms (e.g., AASL
D), prioritizing safety unlike normal labs, this demands provider action, making it the critical value to report.
Question 2 of 5
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
Correct Answer: C
Rationale: Older adults with bladder infections (UTIs) often lack classic symptoms, presenting with altered mental status confusion or lethargy from systemic inflammation or bacteremia, per geriatric care standards. Normal WBC (9,000/mm³) doesn't rule out UTI; leukocytosis isn't always present early. A slight fever (37.3°
C) supports infection but isn't definitive alone. Diminished reflexes tie to aging or neurology, not UTI. Mental status change is a red flag prompting urinalysis and antibiotics preventing sepsis, making it the strongest indicator in this population.
Question 3 of 5
A nurse in a long-term care facility is assisting with the plan of care for a client who has late-stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Late-stage Alzheimer's reduces mobility, heightening pressure ulcer risk. Turning every 2 hours redistributes weight, preserving skin integrity, a preventive standard (e.g., NPUAP guidelines). Mirrors confuse patients unable to recognize themselves, increasing agitation. Written instructions are futile severe cognitive loss prevents comprehension; physical cues work better. Open-ended questions overwhelm, as verbal ability is minimal; simple prompts suit better. Repositioning addresses a physical priority, reduces complications like infection, and upholds care quality, making it the essential action.
Question 4 of 5
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.
Question 5 of 5
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.