ATI PN Adult Medical Surgical 2019

Questions 63

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ATI PN Adult Medical Surgical 2019 Questions

Question 1 of 5

A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which position should the nurse place the client in to relieve these symptoms?

Correct Answer: A

Rationale: Placing the client in High Fowler's position is beneficial for individuals with left-sided heart failure experiencing dyspnea and orthopnea. This position helps to reduce venous return, decrease preload, and enhance respiratory function, thereby relieving the symptoms mentioned. Choice B, the supine position, is not recommended as it may exacerbate dyspnea and orthopnea by increasing preload. Choice C, the Trendelenburg position, is incorrect as it involves the feet being positioned higher than the head, which is not suitable for heart failure patients. Choice D, the Sims' position, is a lateral position used for rectal examination and is not indicated for relieving dyspnea and orthopnea in heart failure.

Question 2 of 5

A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?

Correct Answer: B

Rationale: Taking calcium supplements with meals is a crucial instruction for a client with osteoporosis. Calcium absorption is enhanced when taken with food, and proper calcium intake is essential for managing osteoporosis effectively by promoting bone health and density. Avoiding weight-bearing exercises (Choice A) is incorrect because these exercises help improve bone strength. Limiting vitamin D intake (Choice C) is also incorrect as vitamin D is necessary for calcium absorption. Increasing caffeine intake (Choice D) is not recommended as caffeine can interfere with calcium absorption.

Question 3 of 5

A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which instruction should the nurse include in the client's discharge teaching?

Correct Answer: A

Rationale: Propylthiouracil (PTU) can suppress bone marrow function, increasing the risk of infection, so it is important to report signs of infection promptly.

Question 4 of 5

A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?

Correct Answer: B

Rationale: An activated partial thromboplastin time (aPTT) of 90 seconds is elevated, indicating a risk of bleeding. The appropriate action for the nurse is to notify the healthcare provider. Increasing the heparin infusion rate can further elevate the aPTT, leading to an increased risk of bleeding. Applying pressure to the injection site is not relevant in this situation. Administering protamine sulfate is used to reverse the effects of heparin in cases of overdose or bleeding, but it is not the initial action for an elevated aPTT.

Question 5 of 5

The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?

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.

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