ATI LPN
ATI Medical Surgical Proctored Exam 2019 Quizlet
1. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented?
- A. Obtain a urine specimen for culture and sensitivity.
- B. Encourage the client to schedule a digital rectal exam.
- C. Advise the client to maintain a voiding diary for one week.
- D. Instruct the client in effective techniques for cleansing the glans penis.
Correct answer: B
Rationale: Encouraging the client to schedule a digital rectal exam is the most appropriate nursing action in this situation. This exam can help evaluate for potential prostate enlargement or other issues contributing to the urinary symptoms described by the client. It is important to assess the prostate gland for any abnormalities that may be causing the urinary issues reported by the client.
2. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Weight gain.
- B. Dry mouth.
- C. Sedation.
- D. Shuffling gait.
Correct answer: D
Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.
3. A client is being taught how to use a PCA pump postoperatively. Which statement indicates understanding?
- A. I should wait until the pain is severe before using the PCA pump.
- B. My family can press the button for me when I'm asleep.
- C. I will press the button when I start to feel pain.
- D. I will only press the button once per hour.
Correct answer: C
Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.
4. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?
- A. Insert the suppository 1 cm into the rectum
- B. Insert the suppository 2 cm into the rectum
- C. Insert the suppository past the anal sphincters
- D. Insert the suppository using two fingers
Correct answer: C
Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.
5. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?
- A. Encourage the client to bear down
- B. Apply the external fetal monitor
- C. Provide the client with fluids
- D. Administer IV fluids
Correct answer: B
Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.
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