ATI LPN
ATI LPN Med Surg Exam 7 Questions
Extract:
Vital Signs
1500:
Temperature 37.3°C (99.1°F)
BP 154/64 mm Hg
Heart rate 105/min
Respiratory rate 26/min
Oxygen saturation 99% on room a
Medical History
Cirrhosis
Hypertension, controlled with metoprolol therapy
Type 2 diabetes mellitus. controlled with glipizide therapy
Physical examination
Client presents with decreased level of consciousness, slurred speech and impaired concentration. Client is lethargic, does not respond to questions or simple commands. Pupils round, reactive to light and accommodation. Partner states client has been sleeping during the day and remains awake at night.
skin is dry and jaundiced with petechiae present to arms and legs. S1 S2 heard on auscultation, et pulses on bilateral radial and pedal pulses. Peripheral edema -3 present in bilateral lower extremities. Crackles auscultated in bilateral lower lobes
Abdomen distended with ascites. Hypoactive bowel sounds present in all four quadrants. Partner reports no knowledge of rectal bleeding, states client has been tolerating diet with no nausea or vomiting Client placed in semi-Fowler's position at 45 feet elevated Bed in low position. Partner remains at clients bedside.
Diagnostic Results
1700
Albumin 2.9 g/dL (3.5 to 5 g/dL)
Ammonia 250 mcg/dl (10 to 80 mcg/dl) Sodium 138 mEq/L (136 to 145 mEq/L)
Potassium 4.8 mEa/L (3.5 to 5 m Eq/LI
Fasting glucose 148 mg/dl (70 to 110 mg/d) BUN 18 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg)
Question 1 of 5
The client is exhibiting manifestations of........... due to the client's.............
Correct Answer: A,B
Rationale: Elevated ammonia (250 mcg/dL) causes hepatic encephalopathy, manifesting as altered mental status and lethargy. DKA, dehydration, acute kidney disease, and malnutrition are ruled out by normal creatinine, fluid retention, and moderate glucose levels.
Extract:
Question 2 of 5
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Disseminated intravascular coagulation (DI
C) is characterized by both excessive clotting and bleeding due to inappropriate activation of the clotting cascade, consuming clotting factors and platelets, leading to a paradoxical combination of thrombosis and hemorrhage.
Question 3 of 5
A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?
Correct Answer: C
Rationale: Severe respiratory stridor and deviated trachea indicate a life-threatening airway obstruction, requiring immediate intervention to secure the airway and prevent respiratory failure, which takes precedence over other conditions.
Question 4 of 5
A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Russell's traction involves a sling under the knee to apply traction force on the femur, aiding in alignment and stabilization for proper healing, distinguishing it from other traction types.
Question 5 of 5
A nurse is caring for a client who is suspected to have active laryngeal tuberculosis (TB). Which of the following actions should the nurse plan to take to safely care for this client?
Correct Answer: B
Rationale: A private room with a negative pressure ventilation system is essential for airborne precautions to prevent the spread of TB, ensuring airborne particles do not escape to other areas.