LPN MEDICAL SURGICAL ATI
EXAMINATION 2025/2026
A nurse is caring for a client with a history of congestive heart failure at
risk for development of fluid volume excess. The nurse should monitor
for which of the following that is a manifestation of left sided heart
failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - ANSWER-Dyspnea with a
cough that is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided
heart failure. Left-sided heart failure causes blood to back up in the heart
and lungs with decreased distribution of blood throughout the body.
,Which client problem should receive highest priority when a client is
admitted with an acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - ANSWER-Impaired physical mobility
When setting priorities for nursing care, physiological needs should be
addressed first according to Maslow's Hierarchy of Needs. Reducing the
client's pain will help with other needs, such as hygiene and grooming.
A nurse is caring for a client with hypoparathyroidism. Because of the
potential electrolyte disturbance associated with this diagnosis, the nurse
should observe the client for evidence of which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - ANSWER-Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased
serum calcium levels), which may cause tetany. Involuntary muscle
spasms are a common symptom associated with hypothyroidism.
,A client with glaucoma is admitted for surgery the following day. The
client is to continue treating the glaucoma with pilocarpine (Pilocar) 2%
1 drop 4 times a day. While instilling this medication, an appropriate
nursing action is which of the following?
Instruct the client to blink several times after instillation of the
medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds
after instillation. - ANSWER-Place the medication in the conjunctival
sac applying pressure to the puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to
the puncta for 1 to 2 min to prevent loss of medication into the nasal
lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr
following the injury, the nurse should instruct the client to do which of
the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to
prevent contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
, Keep ice on the ankle to prevent edema. - ANSWER-Keep ice on the
ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing
swelling. Nerve impulse transmission will also be reduced, resulting in
analgesia to the injured area and a reduction of muscle spasms. Ice
applications should not exceed 20 to 30 min per application.
A nurse is assisting with the discharge of a client newly diagnosed with
diabetes. When reviewing information about proper foot care, which of
the following would be appropriate to include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - ANSWER-Wear clean cotton socks
daily.
Cotton socks should be worn by clients who are diabetic. They are soft
and will wick excess moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly
confused, and has a blood pressure of 204/102 mm Hg. The client is also
incontinent of urine. When contributing to the client's plan of care,
which nursing action would be appropriate?
Offer the client a bedpan every 2 hr.
EXAMINATION 2025/2026
A nurse is caring for a client with a history of congestive heart failure at
risk for development of fluid volume excess. The nurse should monitor
for which of the following that is a manifestation of left sided heart
failure?
Swelling of the fingers and hands
Jugular neck vein distension
3+ ankle edema
Dyspnea with a cough that is worse at night - ANSWER-Dyspnea with a
cough that is worse at night
Dyspnea with a cough that is worse at night is an indication of left-sided
heart failure. Left-sided heart failure causes blood to back up in the heart
and lungs with decreased distribution of blood throughout the body.
,Which client problem should receive highest priority when a client is
admitted with an acute exacerbation of rheumatoid arthritis?
Difficulty with hygiene and grooming
Impaired physical mobility
Body-image disturbance
Anxiety - ANSWER-Impaired physical mobility
When setting priorities for nursing care, physiological needs should be
addressed first according to Maslow's Hierarchy of Needs. Reducing the
client's pain will help with other needs, such as hygiene and grooming.
A nurse is caring for a client with hypoparathyroidism. Because of the
potential electrolyte disturbance associated with this diagnosis, the nurse
should observe the client for evidence of which of the following?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss - ANSWER-Involuntary muscle spasms
A decrease in parathormone secretion leads to hypocalcemia (decreased
serum calcium levels), which may cause tetany. Involuntary muscle
spasms are a common symptom associated with hypothyroidism.
,A client with glaucoma is admitted for surgery the following day. The
client is to continue treating the glaucoma with pilocarpine (Pilocar) 2%
1 drop 4 times a day. While instilling this medication, an appropriate
nursing action is which of the following?
Instruct the client to blink several times after instillation of the
medication.
Ask the client to look straight ahead.
Place the medication in the conjunctival sac applying pressure to the
puncta for 1 to 2 min.
Dab excess medication from the eye using a cotton ball 10 to 15 seconds
after instillation. - ANSWER-Place the medication in the conjunctival
sac applying pressure to the puncta for 1 to 2 min.
Eye drops are instilled into the conjunctival sac and pressure applied to
the puncta for 1 to 2 min to prevent loss of medication into the nasal
lacrimal duct and into the systemic circulation.
A client has sprained an ankle while playing soccer. For the first 24 hr
following the injury, the nurse should instruct the client to do which of
the following?
Perform gentle range of motion (ROM) exercises on the ankle joint to
prevent contractures.
Keep moist heat on the ankle to prevent muscle spasm.
Keep the foot in a dependent position to aide circulation to the foot.
, Keep ice on the ankle to prevent edema. - ANSWER-Keep ice on the
ankle to prevent edema.
Ice or cold will constrict blood vessels to the injured area decreasing
swelling. Nerve impulse transmission will also be reduced, resulting in
analgesia to the injured area and a reduction of muscle spasms. Ice
applications should not exceed 20 to 30 min per application.
A nurse is assisting with the discharge of a client newly diagnosed with
diabetes. When reviewing information about proper foot care, which of
the following would be appropriate to include?
Soak feet every night in warm water.
Wear clean cotton socks daily.
Walk barefoot at home when possible.
Get fitted for shoes in the morning. - ANSWER-Wear clean cotton socks
daily.
Cotton socks should be worn by clients who are diabetic. They are soft
and will wick excess moisture away from the foot.
Following a transient ischemic attack (TIA), a client is alert, slightly
confused, and has a blood pressure of 204/102 mm Hg. The client is also
incontinent of urine. When contributing to the client's plan of care,
which nursing action would be appropriate?
Offer the client a bedpan every 2 hr.
