ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?
- A. Apply a heating pad to the ulcer twice daily.
- B. Wear tight-fitting shoes to protect the ulcer.
- C. Keep the ulcer clean and dry.
- D. Limit walking to reduce pressure on the ulcer.
Correct answer: C
Rationale: The correct answer is C: "Keep the ulcer clean and dry." For clients with diabetes mellitus, it is crucial to maintain foot ulcers clean and dry to prevent infection and promote healing. Moist environments can lead to bacterial growth and delay healing. Applying a heating pad (Choice A) can increase the risk of burns and further damage the ulcer. Wearing tight-fitting shoes (Choice B) can cause friction and pressure on the ulcer, hindering the healing process. Limiting walking (Choice D) excessively can affect circulation and delay healing. Therefore, the nurse should instruct the client to keep the ulcer clean and dry for optimal wound care management.
2. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
- A. Place the cap from the solution sterile side up on a clean surface.
- B. Open the outermost flap of the sterile kit away from the body.
- C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
- D. Set up the sterile field 5 cm (2 in) above waist level.
Correct answer: A
Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.
3. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?
- A. Use the cane on the weak side
- B. Maintain two points of support on the ground at all times
- C. Advance the cane 30 to 45 cm with each step
- D. Advance the cane and the strong leg simultaneously
Correct answer: B
Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.
4. What is the primary goal of health education?
- A. To diagnose diseases
- B. To change behavior for improved health
- C. To provide emergency medical care
- D. To perform surgeries
Correct answer: B
Rationale: The primary goal of health education is to empower individuals with knowledge and skills to make informed decisions and adopt behaviors that lead to improved health outcomes. It focuses on promoting healthy habits, disease prevention, and overall well-being.
5. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct answer: B
Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.
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