ATI LPN
ATI LPN Med Surg Level 2 Exam Questions
Extract:
Nurses' Notes Day 1:
Client has a 10.2 cm (4 in) by 10.2 cm (4 in) raised reddened abscess on left thigh. Client reports area is warm and painful.
Vital Signs
Temperature 39.6° C (103.3° F)
Blood pressure 118/56 mm Hg
Heart rate 106/min
Respiratory rate 22/min
Oxygen saturation 96% on room air room.
Diagnostic Results
Day 2
WBC: 45.000/mm3 (5000 to 10.000/mm3)
Culture and sensitivity of left thigh abscess positive for methicillin- resistant Staphylococcus aureus (MRSA)
Question 1 of 5
For each potential nursing action, click to specify if the action is essential, nonessential, or contraindicated for the client with a MRSA abscess.
| Options | Essential | Nonessential | Contraindicated |
|---|---|---|---|
| Place the client in a private room. | |||
| Administer intravenous vancomycin. | |||
| Wear a cover gown when caring for the client. | |||
| Restrict fluid intake. | |||
| Initiate supplemental oxygen. |
Correct Answer: A,B,C
Rationale: Private room, vancomycin, and gowns are essential for MRSA; fluid restriction is contraindicated, and oxygen is nonessential based on normal saturation.
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Question 2 of 5
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Question 3 of 5
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Question 5 of 5
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