ATI LPN
ATI LPN adult medical surgical 2023 Questions
Extract:
Nurses' Notes
Vital Signs
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days. The client states, “I also have vomited, once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
Question 1 of 5
The nurse is assisting with the care of a client. The nurse is collecting data on the client. Which of the following findings require follow-up?
Correct Answer: A,B,C,D
Rationale: Blood pressure, BUN, potassium, and abdominal findings (pain, constipation, vomiting, high-pitched bowel sounds) require follow-up due to potential dehydration or obstruction; breath sounds are normal and do not need follow-up.
Extract:
Question 2 of 5
A nurse is reinforcing teaching about ostomy care with a client who has a new colostomy. Which of the following findings should the nurse instruct the client to report to the provider?
Correct Answer: B
Rationale: A purplish stoma indicates potential ischemia or poor blood supply, requiring prompt reporting to the provider.
Question 3 of 5
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
Correct Answer: D
Rationale: Asking 'What does your pain feel like?' assesses the quality (e.g., sharp, dull), a key component of pain assessment.
Question 4 of 5
A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.
Correct Answer: B,E,C,A,D
Rationale: The sequence is: hand hygiene, remove dressing/tape, clamp tubing, apply pressure, withdraw catheter-ensuring safety and preventing bleeding.
Question 5 of 5
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
Correct Answer: C
Rationale: Using the left arm for blood samples avoids trauma to the right arm, reducing the risk of lymphedema after a right mastectomy.