ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Vital Signs
Today, 0700:
Blood pressure 122/68 mm Hg
Heart rate 99/min
Respiratory rate 20/min
Temperature 36.4° C (97.6° F)
Laboratory Results
Today, 0700:
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
Hct 44% (42% to 52%)
BUN 19 mg/dL (10 to 20 mg/dL)
Question 1 of 5
Which of the following client findings should the nurse identify as a contraindication to the administration of furosemide? (Client with potassium 3.2 mEq/L)
Correct Answer: A
Rationale: Hypokalemia (3.2 mEq/L) is a contraindication as furosemide can worsen it, risking arrhythmias.
Extract:
Question 2 of 5
A nurse is preparing to administer epoetin 50 units/kg via subcutaneous injection to a client who weighs 165 lb and has chronic kidney disease. How many units should the nurse administer?
Correct Answer: A
Rationale: 165 lb = 75 kg; 50 units/kg × 75 kg = 3750 units, correct for stimulating RBC production in CKD.
Question 3 of 5
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
Question 4 of 5
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
Question 5 of 5
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.