ATI LPN adult medical surgical 2023

ATI LPN adult medical surgical 2023 Related

Review ATI LPN adult medical surgical 2023 related questions and content

Nurses' Notes
Vital Signs
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.

The nurse is assisting with the care of a client. The nurse is collecting data on the client. Which of the following findings require follow-up?

  • A. Blood pressure
  • B. BUN level
  • C. Potassium level Abdominal findings
  • D. WBC count
  • E. Breath sounds
Correct Answer: A,B,C,D

Rationale: Blood pressure, BUN, potassium, and abdominal findings (pain, constipation, vomiting, high-pitched bowel sounds) require follow-up due to potential dehydration or obstruction; breath sounds are normal and do not need follow-up.

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A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?

  • A. The client arouses easily but quickly falls back asleep.
  • B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
  • C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
  • D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A

Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.

A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?

  • A. I will lie down for 30 minutes after each meal.
  • B. I will increase vitamin C intake by drinking orange juice.
  • C. I will sleep flat on my back at night.
  • D. I will eat six small meals each day.
Correct Answer: D

Rationale: Eating six small meals reduces stomach pressure and reflux, indicating understanding of GERD management.

A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?

  • A. Cervical cancer screenings should begin at age 40
  • B. Plan to continue cervical cancer screenings for the rest of your life.
  • C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
  • D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C

Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.

A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

  • A. Prefers not to look at the stoma site
  • B. Participates in performing ostomy care
  • C. Denies feelings of sadness about the ostomy
  • D. Accepts that sexual activity will decrease
Correct Answer: B

Rationale: Participating in ostomy care demonstrates acceptance and adaptation to the altered body image.

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

  • A. Perform suctioning.
  • B. Instill saline into the tubing.
  • C. Increase the humidification.
  • D. Check the cuff pressure.
Correct Answer: A

Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.

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