ATI LPN
PN ADULT MEDICAL SURGICAL 2023 Questions
Extract:
Question 1 of 5
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
Correct Answer: C
Rationale: An induration of 15 mm after 48 hours indicates a positive TB skin test, suggesting exposure or infection. Smaller indurations, scabbing, or bruising do not meet the criteria for a positive result.
Question 2 of 5
A nurse is caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Breaking care into small, frequent sessions reduces sensory overload by minimizing stimulation. Open blinds, proximity to the station, and music could worsen overload in cardiomyopathy.
Question 3 of 5
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
Order the Items
Source Container
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 4 of 5
A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
Question 5 of 5
A nurse is contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.