ATI LPN
ATI PN Adult Medical Surgical 2023 III Questions
Extract:
Vital Signs
Nurses’ Notes
Diagnostic Results
Provider’s Prescriptions
Postoperative day 1, 0600:
Temperature: 36.4 C (97.5 F)
Heart rate: 84/min
Respiratory rate: 18/min
Blood pressure: 106/74 mm Hg
Oxygen saturation: 97% on room air
2330:
Temperature: 36.3 C(97.3 F)
Heart rate: 104/min
Respiratory rate: 24/min
Blood pressure: 88/54 mm Hg
Oxygen saturation: 96% on room air
The nurse is continuing to assist in the care of the client.
Question 1 of 5
For each data collection finding, specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than one disease process or none at all.
| Options | Hypovolemic Shock | Pulmonary Embolism |
|---|---|---|
| Respiratory effort | ||
| Heart rate | ||
| Pain | ||
| Blood pressure | ||
| Mentation |
Correct Answer: B,D
Rationale: Tachycardia (heart rate 104/min) and hypotension (88/54 mm Hg) on day 1 at 2330 are consistent with hypovolemic shock due to fluid loss post-surgery.
Extract:
Question 2 of 5
How many mL should the nurse administer with each dose?
Correct Answer: A
Rationale: 15,000 units / 10,000 units/mL = 1.5 mL, calculated for heparin administration.
Extract:
Nurse’s Notes at 0800hrs
Physical Examination Results
Vital Signs at 0800hrs
Provider’s Prescriptions
Diagnostic Results at 0800hrs
The client appears uncomfortable and restless. He is guarding his abdomen, which is distended and tympanic to percussion. His skin is warm and dry to touch, with no signs of jaundice. He continues to deny any tobacco use and admits to drinking 1 to 2 glasses of wine daily.
A nurse is caring for a 52-year-old male client in the emergency department. It’s now 0800hrs. The client reports worsening mid- abdominal pain, rating it as 8 on a scale of 0 to 10. He states, “I haven’t had a bowel movement in 5 days now.” He also mentions that he has vomited twice since the last assessment.
Question 3 of 5
For each finding, specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than one disease process.
| Options | Small Bowel Obstruction | Acute Pancreatitis |
|---|---|---|
| Abdominal Pain | ||
| No Bowel Movement for 5 days | ||
| Vomiting | ||
| Abdominal Distention | ||
| Increased Heart Rate | ||
| Elevated Temperature | ||
| Distention with fluid and gas in the small bowel (CT Scan) |
Correct Answer: A
Rationale: Abdominal pain is consistent with both small bowel obstruction (due to blockage) and acute pancreatitis (due to inflammation). However, the constellation of findings (no bowel movement, vomiting, distention) leans toward small bowel obstruction, confirmed by CT scan findings.
Extract:
Question 4 of 5
What advice should the nurse provide?
Correct Answer: D
Rationale: A diary correlates activities with heart rhythms, essential for Holter monitor interpretation.
Question 5 of 5
Which of the following instructions should be included by the nurse?
Correct Answer: C
Rationale: Room temperature storage of opened insulin for up to 4 weeks ensures stability and safety.