ATI LPN
Medical Surgical ATI Proctored Exam
1. A client with portal hypertension who has developed ascites is scheduled for a paracentesis. What pre-procedure nursing intervention is essential?
- A. Encourage the client to empty the bladder
- B. Administer a laxative to clear the bowels
- C. Restrict the client's fluid intake
- D. Place the client in a supine position
Correct answer: A
Rationale: Emptying the bladder before a paracentesis is essential to prevent bladder injury during the procedure. A full bladder may be in the path of the needle insertion, increasing the risk of bladder puncture. Encouraging the client to empty the bladder ensures their safety and reduces the likelihood of complications.
2. A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?
- A. Capillary refill
- B. Bowel sounds
- C. Temperature
- D. Oxygen saturation
Correct answer: D
Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.
3. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?
- A. Use a tuberculin syringe.
- B. Insert the needle at a 45-degree angle.
- C. Use a 1-inch needle.
- D. Aspirate before injecting.
Correct answer: A
Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.
4. What should a person recommend to a client experiencing constipation?
- A. Increase fluid intake to prevent further dehydration
- B. Increase dietary fiber to promote regular bowel movements
- C. Administer a laxative to relieve constipation
- D. Encourage bed rest to allow for bowel function to return
Correct answer: B
Rationale: Increasing dietary fiber is an effective recommendation for clients experiencing constipation as it helps promote regular bowel movements. Choice A, increasing fluid intake, is also important but the most appropriate initial recommendation for constipation is to increase dietary fiber. Choice C, administering a laxative, should not be the first-line recommendation and is typically considered after dietary and lifestyle interventions. Choice D, encouraging bed rest, does not directly address constipation relief or prevention.
5. The nursing assistant asks the nurse to explain the meaning of advocacy. The nurse explains that the fundamental principle of patient advocacy is what?
- A. Independence
- B. Caring
- C. Competence
- D. Protection
Correct answer: D
Rationale: The correct answer is D: Protection. Protection is the fundamental principle of patient advocacy, ensuring that patients' rights and interests are safeguarded. Advocacy involves actively speaking up for the patient, ensuring they receive proper care, their wishes are respected, and they are protected from harm or exploitation. It goes beyond independence, caring, and competence, focusing on safeguarding the patient's well-being and ensuring their rights are upheld. While independence, caring, and competence are important aspects of patient care, they do not encompass the core principle of advocacy, which is to protect the patient's rights and well-being.
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