ATI LPN
ATI Learning System PN Medical Surgical Final Quizlet
1. What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?
- A. Test stools for the presence of blood.
- B. Maintain a low-residue, high-fiber diet.
- C. Clean the perianal area carefully after every bowel movement.
- D. Inspect the mouth and throat daily for signs of thrush.
Correct answer: C
Rationale: When a patient with cervical cancer is receiving external-beam radiation, the radiation to the abdomen can affect organs in its path, such as the bowel, leading to complications like frequent diarrhea. Cleaning the perianal area carefully after each bowel movement is crucial to decrease the risk of skin breakdown and infection. Testing stools for blood is not necessary since inflammation associated with radiation may lead to occult blood in stools. Maintaining a low-residue diet is actually recommended to prevent bowel irritation. Radiation to the abdomen does not cause stomatitis, so inspecting the mouth and throat for thrush is not directly related to the effects of external-beam radiation in this context.
2. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.
3. A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct answer: D
Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT. Applying a warm compress (Choice A) could worsen the condition by increasing blood flow. Elevating the leg (Choice B) might be contraindicated in DVT as it can dislodge a clot. Measuring the circumference of the leg (Choice C) is not the priority at this time compared to promptly involving the healthcare provider.
4. The LPN/LVN is assisting in the care of a client with a diagnosis of heart failure who is receiving digoxin (Lanoxin). Which laboratory result should the nurse monitor closely?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum glucose
Correct answer: B
Rationale: The correct answer is serum potassium. Monitoring serum potassium levels is crucial when a client is receiving digoxin (Lanoxin) because low potassium levels can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac complications, such as arrhythmias. Therefore, close monitoring of serum potassium is essential to prevent adverse effects and ensure the safe administration of digoxin in clients with heart failure. Serum sodium, serum calcium, and serum glucose levels are also important laboratory values to monitor in clients with heart failure, but they are not directly associated with the risk of digoxin toxicity. Monitoring these values helps in assessing overall health status, fluid balance, and metabolic functions in the client.
5. Nurse M obtains a signature on an informed consent form from Mr. Y, who is later shown to have a fluctuating level of mental competency. In this case, what is Nurse M's most likely legal position?
- A. Freedom from liability because Mr. Y signed the form
- B. Possibly liable for a violation of Mr. Y's rights
- C. Liable unless a malpractice insurance policy is in effect
- D. Not liable because no family member had a durable power of attorney
Correct answer: B
Rationale: An informed consent may be considered invalid if the patient does not fully understand what he or she is signing. Patients with a fluctuating level of mental function are incapable of granting legally sound consent. Nurse M could be held liable for a violation of Mr. Y's rights as he did not have the capacity to provide informed consent. The presence of an insurance policy and the legal status of family members are irrelevant in this context and do not absolve Nurse M of potential liability.
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