ATI LPN adult medical surgical 2023 | Nurselytic

Questions 61

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ATI LPN adult medical surgical 2023 Questions

Extract:

Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
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


Question 1 of 5

Which of the following actions should the nurse assist with?

Correct Answer: C

Rationale: Reinforcing preoperative teaching is appropriate given the potential need for surgery due to suspected bowel obstruction, as indicated by symptoms.

Extract:

Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
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.

Day 1, 1100:

Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.

Day 4, 1000:

Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.

Physical exam:

General: Appears more comfortable, not grimacing.

HEENT: Mucous membranes moist.

Cardiovascular: S1, S2, no murmur.

Respiratory: Bilateral breath sounds clear.

Gastrointestinal:

Mild tenderness to palpation.

Bowel sounds present and more regular, less high-pitched.

Skin: No jaundice noted, skin warm and dry.

The nurse continues to assist with the care of the client.


Question 2 of 5

The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?

Correct Answer: D,E,F

Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.

Extract:


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 contributing to the plan of care for a client who has had severe diarrhea for the past 3 days and is now beginning solid foods. Which of the following foods should the nurse include in the plan of care?

Correct Answer: A

Rationale: Applesauce is gentle on the digestive system and helps firm stools, suitable for reintroducing solids after diarrhea.

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