ATI LPN
ATI PN Adult Medical Surgical 2019
1. What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?
- A. Secure the tracheostomy ties firmly.
- B. Change the tracheostomy tube daily.
- C. Use the minimal leak technique when inflating the cuff.
- D. Clean the stoma with hydrogen peroxide.
Correct answer: C
Rationale: To prevent tracheal tissue damage in a client with a tracheostomy, the nurse should use the minimal leak technique when inflating the cuff. This method helps avoid excessive pressure on the tracheal tissue, thereby reducing the risk of damage. Choice A is incorrect because securing the tracheostomy ties too tightly can cause pressure and tissue damage. Choice B is incorrect as changing the tracheostomy tube daily is not necessary unless there is a specific clinical indication. Choice D is incorrect as cleaning the stoma with hydrogen peroxide can irritate the skin and mucous membranes, potentially leading to damage.
2. A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct answer: A
Rationale: The correct response is A: 'The cancer involves only the cervix.' In staging, 'Tis' indicates cancer in situ, which means it is localized to the cervix and not invasive at this time. The differentiation of cancer cells is not part of clinical staging. Since the cancer is in situ, its origin is the cervix. Further testing is not required as the cancer has not spread beyond the cervix. Choice B is incorrect as the staging information provided does not relate to the resemblance of cancer cells to normal cells. Choice C is incorrect because further testing is not necessary as the cancer is localized. Choice D is incorrect because the staging information provided clearly indicates the site of origin as the cervix.
3. A healthcare professional is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate. What state resource is most likely to provide this information?
- A. Disease registry.
- B. Department of Health.
- C. Bureau of Vital Statistics.
- D. Census data.
Correct answer: C
Rationale: The Bureau of Vital Statistics collects data on births and deaths, including infant mortality rates. This data is crucial for healthcare professionals to analyze and compare rates between different regions.
4. A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct answer: C
Rationale: In cases of major depressive disorder where the client is non-participatory and withdrawn, sitting with the client and providing support without pressuring them to engage in activities like eating or therapy is crucial. This approach respects the client's current state, builds trust, and creates a supportive environment that can eventually lead to the client opening up and accepting help.
5. What should the nurse include in patient teaching for a patient prescribed ceftriaxone for bacterial pneumonia?
- A. Take the medication as prescribed.
- B. Expect urine color changes.
- C. Complete the full course of the antibiotic.
- D. Avoid dairy products during treatment.
Correct answer: C
Rationale: When educating a patient prescribed ceftriaxone for bacterial pneumonia, it is crucial to emphasize completing the full course of the antibiotic. Completing the full course helps ensure the infection is completely eradicated and reduces the risk of antibiotic resistance. Incomplete courses of antibiotics can lead to treatment failure and the development of resistant bacterial strains. Therefore, it is essential for patients to adhere to the prescribed treatment regimen to achieve optimal outcomes.
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