ATI LPN
ATI LPN Med Surg Level 2 Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?
Correct Answer: C
Rationale: Hyperthermia (fever) is a systemic response to infection, indicating the body's immune system is fighting the infection.
Question 2 of 5
When performing dressing changes in an older client, what should the nurse assess for?
Correct Answer: A
Rationale: Older adults are prone to infections due to weakened immune systems, making it critical to assess for signs like redness or drainage.
Question 3 of 5
The nurse in a healthcare provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?
Correct Answer: D
Rationale: Skin changes can reflect systemic issues, making it a key health indicator.
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 4 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.
Extract:
Question 5 of 5
A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes for one week. For which part of the prescription does the nurse clarify with the physician?
Correct Answer: D
Rationale: Clarification is needed to confirm the saline's temperature, as it may affect wound healing.