ATI LPN
Adult Medical Surgical ATI
1. Which of the following statements about Helicobacter pylori (H. pylori) is false?
- A. H. pylori does not invade the gastric or duodenal epithelium
- B. H. pylori stimulates gastric acid secretion
- C. Eradication of H. pylori prevents adenocarcinoma of the stomach
- D. H. pylori produces a urease that splits urea into ammonia and CO2
Correct answer: C
Rationale: H. pylori is known to reside in the mucus layer of the stomach and does not invade the epithelium. It produces urease that splits urea into ammonia and CO2. This action helps in neutralizing the acidic environment and allows H. pylori to survive. Additionally, urease activity can be detected in diagnostic tests for H. pylori. The stimulation of gastric acid secretion and disruption of the protective mucus layer are mechanisms by which H. pylori promotes injury. While eradicating H. pylori infection has been associated with a decreased risk of developing gastric cancer, it does not prevent adenocarcinoma of the stomach entirely.
2. The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
- A. Warm skin, hypertension, and constricted pupils.
- B. Bradycardia, hypotension, and respiratory acidosis.
- C. Mottled skin, tachypnea, and hyperactive bowel sounds.
- D. Tachycardia, mental status change, and low urine output.
Correct answer: D
Rationale: Tachycardia, mental status change, and low urine output are early indicators of shock. In a critically ill client, these findings suggest a decrease in tissue perfusion. Prompt recognition and intervention are crucial to prevent the progression of shock and its complications.
3. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Hyperactivity
- D. Hyperglycemia
Correct answer: D
Rationale: The correct answer is D: Hyperglycemia. Risperidone (Risperdal) can lead to metabolic side effects, such as hyperglycemia, which requires monitoring. Choice A, Hypertension, is incorrect because risperidone is not typically associated with hypertension. Choice B, Weight loss, is less common with risperidone use as it can lead to weight gain. Choice C, Hyperactivity, is not a common side effect of risperidone; instead, it is more known for sedative effects.
4. After a client's neck dissection surgery resulted in damage to the superior laryngeal nerve, what area of assessment should the nurse prioritize?
- A. The client's swallowing ability
- B. The client's ability to speak
- C. The client's management of secretions
- D. The client's airway patency
Correct answer: A
Rationale: Damage to the superior laryngeal nerve can lead to swallowing difficulties due to impaired laryngeal function. As a result, assessing the client's swallowing ability is crucial to prevent aspiration and ensure proper nutrition and hydration.
5. When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation in the water seal chamber.
- D. Steady bubbling in the suction control chamber.
Correct answer: D
Rationale: Steady bubbling in the suction control chamber is the correct observation that indicates the chest tube is functioning properly. This steady bubbling signifies that the suction is actively maintaining the desired pressure level within the system, ensuring proper drainage and lung re-expansion. Continuous bubbling in the water seal chamber, intermittent bubbling in the suction control chamber, or no fluctuation in the water seal chamber are not indicative of optimal chest tube function and may require further assessment or intervention.
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