ATI LPN
PN Adult Medical Surgical 2023 Questions
Extract:
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Question 1 of 5
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.
Extract:
Question 2 of 5
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.
Question 3 of 5
A nurse is reinforcing teaching with a client who will be wearing a Holter monitor for the next 24 hr. Which of the following information should the nurse include?
Correct Answer: A
Rationale: Recording activities helps correlate symptoms with heart activity; electrodes stay on, and bathing is avoided.
Question 4 of 5
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.
Question 5 of 5
A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Weighing before and after tracks fluid removal in peritoneal dialysis, assessing treatment effectiveness. Dialysate is warmed, diarrhea isn't a primary concern, and sterile gloves are preferred.