ATI RN MEDICAL SURGICAL WITH NGN
2024-2025 COMPLETE 180 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES |GRADED A+
A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair - Correct Answer -- Places body weight on the
crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
- Constipation
- Insomnia
- Tachycardia
- Diaphoresis - Correct Answer -- Constipation
RATIONALE: A client who has hypothyroidism can experience constipation due to the
decrease in the client's metabolism, resulting in slow motility of the GI tract. The nurse
should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.
1
,A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the
following nonpharmacological interventions should the nurse suggest to the client to reduce
pain?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints - Correct Answer -- Alternate application of heat and
cold to the affected joints
RATIONALE: The nurse should instruct the client to alternate heat and cold applications to
decrease joint inflammation and pain. The application of cold can relieve joint swelling and
the application of heat can decrease joint stiffness and pain.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities - Correct Answer -- Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are
manifestations of circulatory overload. The nurse should slow or stop the infusion to improve
the client's ability to breath, place the client in an upright position, and notify the provider.
The provider might prescribe a diuretic to alleviate the fluid overload.
A nurse in the emergency department is assessing a client who has a detached retina. Which
of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks."
- "I seem to have more problems seeing different colors." - Correct Answer -- "It's like a
curtain closed over my eye."
2
,RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can
occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled over part of the visual
field.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat - Correct Answer -- Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet
that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as
cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take? (Select all that apply.)
- Ask the client to rate their pain on a 0 to 10 pain scale
- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Apply oxygen via a face mask
- Report urinary output to the provider - Correct Answer -- Instruct the client to splint the
abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and deep breathe to reduce the risk
for respiratory complications. The nurse should instruct the client to splint the incision while
performing these actions to reduce the risk of complications to the surgical incision.
- Plan to ambulate the client as soon as possible
3
, RATIONALE: The nurse should plan to ambulate the client as soon as possible to promote
ventilation and decrease the risk of thrombosis..
- Report urinary output to the provider
RATIONALE: The client should produce at least 30 mL of urine per hour. Therefore, the
nurse should report this finding to the provider.
- Ask the client to rate their pain on a 0 to 10 pain scale
RATIONALE: The nurse should have the client rate their pain prior to and following the
administration of pain medication to evaluate its effectiveness.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following findings indicates that the client is experiencing a complication?
- The client reports that the sequential compression devices (SCDs) are uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to drainage
- The client needs assistance with a walker when ambulating in the room - Correct Answer --
The client's surgical site dressing has required changing twice in 2 hr due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor clotting and
increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed with
food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs - Correct Answer -- Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to assess the
client's vital signs. A client who has portal HTN can develop esophageal varices, which are
4
2024-2025 COMPLETE 180 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES |GRADED A+
A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper
use of crutches while climbing stairs. Identify the sequence the client should follow when
demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair - Correct Answer -- Places body weight on the
crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations
should the nurse expect?
- Constipation
- Insomnia
- Tachycardia
- Diaphoresis - Correct Answer -- Constipation
RATIONALE: A client who has hypothyroidism can experience constipation due to the
decrease in the client's metabolism, resulting in slow motility of the GI tract. The nurse
should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.
1
,A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the
following nonpharmacological interventions should the nurse suggest to the client to reduce
pain?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints - Correct Answer -- Alternate application of heat and
cold to the affected joints
RATIONALE: The nurse should instruct the client to alternate heat and cold applications to
decrease joint inflammation and pain. The application of cold can relieve joint swelling and
the application of heat can decrease joint stiffness and pain.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities - Correct Answer -- Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are
manifestations of circulatory overload. The nurse should slow or stop the infusion to improve
the client's ability to breath, place the client in an upright position, and notify the provider.
The provider might prescribe a diuretic to alleviate the fluid overload.
A nurse in the emergency department is assessing a client who has a detached retina. Which
of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks."
- "I seem to have more problems seeing different colors." - Correct Answer -- "It's like a
curtain closed over my eye."
2
,RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can
occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled over part of the visual
field.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat - Correct Answer -- Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet
that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as
cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take? (Select all that apply.)
- Ask the client to rate their pain on a 0 to 10 pain scale
- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Apply oxygen via a face mask
- Report urinary output to the provider - Correct Answer -- Instruct the client to splint the
abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and deep breathe to reduce the risk
for respiratory complications. The nurse should instruct the client to splint the incision while
performing these actions to reduce the risk of complications to the surgical incision.
- Plan to ambulate the client as soon as possible
3
, RATIONALE: The nurse should plan to ambulate the client as soon as possible to promote
ventilation and decrease the risk of thrombosis..
- Report urinary output to the provider
RATIONALE: The client should produce at least 30 mL of urine per hour. Therefore, the
nurse should report this finding to the provider.
- Ask the client to rate their pain on a 0 to 10 pain scale
RATIONALE: The nurse should have the client rate their pain prior to and following the
administration of pain medication to evaluate its effectiveness.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of
the following findings indicates that the client is experiencing a complication?
- The client reports that the sequential compression devices (SCDs) are uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to drainage
- The client needs assistance with a walker when ambulating in the room - Correct Answer --
The client's surgical site dressing has required changing twice in 2 hr due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor clotting and
increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed with
food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs - Correct Answer -- Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to assess the
client's vital signs. A client who has portal HTN can develop esophageal varices, which are
4
