ATI LPN
ATI LPN Med Surg Exam 7 Questions
Extract:
Question 1 of 5
The nurse is reviewing the record of a client with a diagnoses of Cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having the client extend their arms and dorsiflex wrists, looking for a flapping tremor. Other options assess unrelated conditions.
Question 2 of 5
A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?
Correct Answer: C
Rationale: Chest compressions at 100-120/min ensure effective circulation during CPR, adhering to current resuscitation guidelines.
Question 3 of 5
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take?
Correct Answer: B,C,D,E
Rationale: Sterile technique, patent tubing, reporting voiding urges, and notifying about bright red urine or clots ensure safe irrigation and prevent complications.
Question 4 of 5
A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?
Correct Answer: C,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin maceration, key risks in paralyzed clients.
Question 5 of 5
A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following client behaviors should alert the nurse that the client is having difficulty adjusting to the loss of her breast?
Correct Answer: A
Rationale: Refusing to look at the incision suggests difficulty accepting the body change, indicating potential body image issues or emotional distress.