ATI LPN
Adult Medical Surgical ATI
1. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?
- A. Disturbed thought processes.
- B. Altered sleep pattern.
- C. Imbalanced nutrition: less than.
- D. Risk for injury.
Correct answer: D
Rationale: The correct answer is 'Risk for injury.' In a client with dementia who is disoriented, wandering, and experiencing sleep disturbances, the priority nursing problem is the risk for injury. Disorientation and wandering behavior can lead to accidents, falls, or other harmful situations, making it crucial for the nurse to address the safety concerns first to prevent any potential harm to the client.
2. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct answer: C
Rationale: Activated partial thromboplastin time (aPTT) is the appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works by prolonging the clotting time, which is reflected in the aPTT results. Monitoring aPTT helps ensure the patient is within the therapeutic range and not at risk of bleeding or clotting complications. Prothrombin time (PT) (Choice A) primarily measures the extrinsic pathway of coagulation and is used to monitor warfarin therapy, not heparin. Platelet count (Choice B) assesses the number of platelets present in the blood and is not specific to monitoring heparin therapy. International normalized ratio (INR) (Choice D) is used to monitor warfarin therapy, not heparin.
3. A healthcare provider is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following statements should the healthcare provider include?
- A. Avoid using a soft toothbrush.
- B. Report any signs of bleeding.
- C. Increase your intake of leafy green vegetables.
- D. Take the medication with food.
Correct answer: B
Rationale: The correct answer is to instruct the client to report any signs of bleeding when taking warfarin. Warfarin is an anticoagulant medication that increases the risk of bleeding, so it is essential to monitor for any signs of abnormal bleeding and report them promptly for appropriate management. Choices A, C, and D are incorrect. Instructing the client to avoid using a soft toothbrush is not directly related to warfarin therapy. Increasing the intake of leafy green vegetables is not recommended as they contain vitamin K, which can interfere with warfarin's anticoagulant effects. Taking warfarin with food can be inconsistent and may not result in optimal absorption.
4. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?
- A. Swelling in the limb
- B. Decreased heart rate
- C. Increased appetite
- D. Improved mobility
Correct answer: A
Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.
5. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?
- A. Weighing the diapers
- B. Inserting a Foley catheter
- C. Comparing intake with output
- D. Measuring the amount of water added to formula
Correct answer: A
Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.
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