ATI LPN adult medical surgical 2023

ATI LPN adult medical surgical 2023 Related

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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.

A nurse is assisting with the care of the client Complete the following sentence by using the list of options. The nurse should first plan to.... followed by.....

  • A. Determine if the nasogastric tube is in the correct position
  • B. Provide oral care to the client
  • C. Increase nasogastric tube suction
  • D. Request a prescription for an antiemetic
  • E. Document the client's pain level
  • F. Monitor the client's electrolyte levels
Correct Answer: A,D

Rationale: The nurse should first ensure the nasogastric tube is correctly placed to address vomiting and obstruction, followed by requesting an antiemetic to manage nausea.

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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?

  • A. There is no cure for MRSA.
  • B. We will need to wear masks when we are in the hospital room.
  • C. MRSA only occurs in health care facilities.
  • D. We should remove gloves before leaving the hospital room.
Correct Answer: D

Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

  • A. It is common for the skin on my breasts to dimple.
  • B. I will perform breast exams every other month.
  • C. It is common for one breast to be larger than the other.
  • D. I will perform breast exams the day my period begins.
Correct Answer: C

Rationale: It is normal for one breast to be slightly larger than the other, and this statement reflects an understanding of breast self-examination teaching.

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

  • A. Changed mental status
  • B. Temperature 37.3°C (99.1°F)
  • C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
  • D. Diminished reflexes
Correct Answer: A

Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

  • A. Clamp the tube for 30 min every 8 hr.
  • B. Pin the tubing to the client's bed sheets.
  • C. Monitor for at least 150 mL of drainage every hour.
  • D. Replace the unit when the drainage chamber is full.
Correct Answer: D

Rationale: Replacing the unit when the drainage chamber is full ensures proper function and prevents complications, such as obstruction or infection, in a closed-chest tube system.

A nurse is transporting a client who has pneumonia and is on droplet precautions to radiology. Which of the following safety measures should the nurse take while transporting the client?

  • A. The client should wear a mask during transport.
  • B. The nurse should wear a mask during transport.
  • C. The nurse should wear a gown during transport.
  • D. The client should wear a gown during transport.
Correct Answer: A

Rationale: The client wearing a mask during transport prevents the spread of droplet pathogens, consistent with droplet precautions for pneumonia.

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