ATI LPN
ATI PN Adult Medical Surgical 2019
1. The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?
- A. Thickened and hardened skin.
- B. Painless ulcers on the fingertips.
- C. Episodes of cyanosis and pallor in the fingers.
- D. Red, scaly patches on the hands.
Correct answer: C
Rationale: Raynaud's phenomenon is characterized by vasospasm, leading to episodes of cyanosis (bluish discoloration) and pallor (pale color) in the fingers or toes, often triggered by cold temperatures or stress. This occurs due to the reduced blood flow during vasospastic episodes, causing the discoloration. Choices A, B, and D are incorrect findings associated with other conditions and are not typical of Raynaud's phenomenon.
2. In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)
- A. Client has delivered one newborn at term
- B. Client has experienced no preterm labor
- C. Client has had two prior pregnancies
- D. ALL OF THE ABOVE - has one living child
Correct answer: D
Rationale: The client's health record data is interpreted as follows: G3 (gravida 3 - total number of pregnancies), T1 (term births - number of full-term deliveries), P0 (preterm births - number of preterm deliveries), A1 (abortions/miscarriages - total number of miscarriages or abortions), L1 (living children - total number of living children). Therefore, the client has had three pregnancies, one full-term delivery, no preterm labor, one miscarriage/abortion, and one living child. The correct interpretation is that the client has delivered one newborn at term, experienced no preterm labor, had two prior pregnancies, and has one living child. Therefore, choice D is correct. Choices A, B, and C are incorrect as they do not provide a comprehensive interpretation of all aspects of the client's health record data.
3. What is the first intervention for a patient in shock?
- A. Administer fluids
- B. Monitor blood pressure
- C. Provide oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.
4. Which of the following aspects of gerontological nursing would be most likely classified under private law?
- A. The regulation of who may call himself or herself a 'nurse'
- B. The contract between an older adult resident of a care facility and the owners of the facility
- C. The legal criteria for declaring an individual mentally incompetent
- D. The criminal consequences for instances of elder abuse
Correct answer: B
Rationale: The correct answer is B because private law deals with relationships between individuals and organizations, such as the contract between an individual and the care facility. Choices A, C, and D are not classified under private law. Choice A pertains to professional regulation and is a matter of public law. Choice C involves legal criteria and decision-making related to mental competence, falling under public law. Choice D concerns criminal consequences, which are also part of public law.
5. A client is being discharged with a prescription for furosemide. Which of the following instructions should be included?
- A. Avoid foods high in potassium.
- B. Monitor your weight daily.
- C. Take the medication with food.
- D. Change positions slowly.
Correct answer: D
Rationale: The correct instruction to include for a client being discharged with a prescription for furosemide is to 'Change positions slowly.' Furosemide, a diuretic, can cause dizziness and orthostatic hypotension, increasing the risk of falls. By advising the client to change positions slowly, the body can adjust to postural changes gradually, reducing the likelihood of falls and related injuries.
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