ATI LPN
Adult Medical Surgical ATI
1. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
- A. Delirium
- B. Presbyopia
- C. Presbycusis
- D. Cerebral dysfunction
Correct answer: C
Rationale: The correct answer is C, Presbycusis. Presbycusis is age-related hearing loss that often affects the ability to hear high-pitched sounds, making speech appear mumbled. This condition is common in older adults and can lead to difficulties in understanding conversations, as in the case of the client complaining about people whispering and mumbling.
2. A patient with hypertension is prescribed lisinopril. What side effect should the nurse monitor for?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Bradycardia
- D. Constipation
Correct answer: A
Rationale: When a patient is prescribed lisinopril, an ACE inhibitor, the nurse should monitor for hyperkalemia. Lisinopril can cause hyperkalemia by decreasing aldosterone secretion, which leads to potassium retention in the body. Hyperkalemia is a potential side effect of ACE inhibitors and should be closely monitored, as it can have serious consequences such as affecting cardiac function.
3. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?
- A. Use sterile gloves
- B. Lubricate the catheter with water
- C. Insert the catheter using clean technique
- D. Open the catheterization kit away from the body
Correct answer: D
Rationale: The correct action for the nurse to take when preparing to insert an indwelling urinary catheter is to open the catheterization kit away from the body. This is crucial to maintain the sterility of the kit and the procedure. Using sterile gloves (Choice A) is important, but it is not specific to this step. Lubricating the catheter with water (Choice B) is incorrect as it should be lubricated with a water-soluble lubricant. Inserting the catheter using clean technique (Choice C) is incorrect as indwelling urinary catheter insertion requires sterile technique to prevent infections.
4. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct answer: C
Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.
5. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsened with breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.
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