ATI LPN
ATI LPN adult medical surgical 2023 Questions
Extract:
A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses.
Day 3, 2300:
Client is alert and oriented to person, place, and time. Bilateral breath sounds clear and present throughout. Right leg with splint in place. Incisional dressing dry and intact. Wound drain to negative-pressure vacuum, draining small amounts of serosanguinous fluid. Bilateral pedal pulses 3+. feet warm with intact movement and sensation. Client reports pain as a 4 on a scale of 0 to 10.
Question 1 of 5
The nurse is reviewing the client's electronic medical record (EMR). Select statements in the EMR that indicate the client's condition is improving since implementing interventions.
Correct Answer: B,C,D
Rationale: Alertness, clear breath sounds, and warm feet with intact sensation indicate recovery from the initial injury and fasciotomy.
Extract:
Question 2 of 5
A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.
Question 3 of 5
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
Question 4 of 5
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
Question 5 of 5
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.