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ATI - Adult Medical Surgical NGN B
A nurse is providing teaching to a client who is perimenopausal and has a
prescription for hormone replacement therapy. For which of the following adverse
effects should the nurse instruct the client to notify the provider? - CORRECT
ANSWER-Calf pain
Numbness in the arms
Intense headache
A nurse is planning care for a client who is postoperative following a laparotomy
and has a closed-suction drain. Which of the following actions should the nurse
take to manage the drain? - CORRECT ANSWER-Compress the drain reservoir
after emptying.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving? - CORRECT
ANSWER-Glucose 272 mg/dL
A nurse is reviewing the laboratory findings of a client who developed chest pain
6 hr ago. The nurse should identify which of the following findings as an
indication of a myocardial infarction (MI)? - CORRECT ANSWER-Troponin I 8
ng/mL
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders
presents the greatest risk to this group of clients? - CORRECT
ANSWER-hypertension
A nurse is providing education to a client who is at risk for osteoporosis. Which of
the following instructions should the nurse include? - CORRECT ANSWER-Walk
for 30 min four times per week.
A nurse is caring for a client who has an arterial line. Which of the following
actions should the nurse take? - CORRECT ANSWER-Place a pressure bag
around the flush solution.
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A nurse is reviewing the ABG results of a client who has advanced COPD. Which
of the following results should the nurse expect? - CORRECT ANSWER-PaCO2
56
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
CORRECT ANSWER-Flex the foot every hour when awake.
A nurse is planning care for a client who is postoperative following a
parathyroidectomy. Which of the following actions should the nurse identify as the
priority? - CORRECT ANSWER-Place a tracheostomy tray at the bedside.
A nurse is evaluating the plan of care for four clients after 2 days of
hospitalization. The nurse should identify the need to revise the plan for which of
the following clients? - CORRECT ANSWER-A client who is postoperative
following abdominal surgery and reports feeling that something "popped" when
they coughed
A nurse is checking the ECG rhythm strip for a client who has a temporary
pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex.
Which of the following actions should the nurse take? - CORRECT
ANSWER-Document that depolarization has occurred.
A nurse is providing discharge instructions to a client who has active tuberculosis
(TB). Which of the following information should the nurse include in the
instructions? - CORRECT ANSWER-Sputum specimens are necessary every 2
to 4 weeks until there are three negative cultures.
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? - CORRECT
ANSWER-Slow the infusion rate
A nurse is assessing a client who is postoperative following a thyroidectomy.
Which of the following findings is the nurse's priority? - CORRECT
ANSWER-Temperature 38.9° C (102° F)
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A nurse is caring for a client who has homonymous hemianopsia as a result of a
stroke. To reduce the risk of falls when ambulating, the nurse should provide
which of the following instructions to the client? - CORRECT ANSWER-Scan the
environment by turning your head from side to side.
A PACU nurse is assessing a client who is postoperative following a right
nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure
130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.80 F). Which
of the following vital sign changes should alert the nurse that the client might be
hemorrhaging? - CORRECT ANSWER-Heart rate 110/min
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - CORRECT ANSWER-Scan the bladder with
a portable ultrasound.
A nurse is assessing a client who has advanced lung cancer and is receiving
palliative care. The client has just undergone thoracentesis. The nurse should
expect a reduction in which of the following common manifestations of advanced
cancer? - CORRECT ANSWER-Dyspnea
A nurse is caring for a client who is postoperative. - CORRECT
ANSWER-Nurses' Notes
Client admitted to medical-surgical unit from PACU. Client reports incisional pain
as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water.
Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for
the past 2 hr. Moderate amount of bright red drainage noted on surgical incision
dressing.
Vital Signs
Temperature 37.6° C (99.7° F)
Heart rate 114/min
Respiratory rate 22/min
Blood pressure 88/54 mm Hg
Oxygen saturation 93% on room air
Diagnostic Results
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Hgb 18 g/dL (12 to 16 g/dL)
Hct 54% (37% to 47 %)
Total WBC count 11,000/mm3 (5,000 to 10,000/mm3)
Troponin T 0.04 ng/mL (less than 0.1 ng/mL)
Medical History.
History of hypertension. Acute myocardial infarction 1 year ago.
Complete the diagram by dragging from the choices below to specify what
condition the client is most likely experiencing, two actions the nurse should take
to address that condition, and two parameters the nurse should monitor to
assess the client's progress. - CORRECT ANSWER-The nurse should insert a
large-gauge IV and initiate a fluid challenge because the client is most likely
experiencing hypovolemia as evidenced by the client's restlessness, tachycardia,
hypotension, decreased pulses, cool extremities, and decreased urine output.
The nurse should monitor the client's urine output and blood pressure to evaluate
the effectiveness of treatment.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - CORRECT ANSWER-Change
position every hour
A nurse is performing a preoperative assessment for a client. The nurse should
identify that an allergy to which of the following foods can indicate a latex allergy?
- CORRECT ANSWER-avocados
- CORRECT ANSWER-Vital Signs
Blood pressure 155/98 mm Hg
Heart rate 98/min
Respiratory rate 14/min
Temperature 38.4° C (101.1 ° F)
Medication Administration Record
Gentamicin 60 mg intermittent IV bolus Q8H
Ceftriaxone 1 g intermittent IV bolus BID
Morphine 2.5 mg IV bolus Q3H PRN for pain
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ATI - Adult Medical Surgical NGN B
A nurse is providing teaching to a client who is perimenopausal and has a
prescription for hormone replacement therapy. For which of the following adverse
effects should the nurse instruct the client to notify the provider? - CORRECT
ANSWER-Calf pain
Numbness in the arms
Intense headache
A nurse is planning care for a client who is postoperative following a laparotomy
and has a closed-suction drain. Which of the following actions should the nurse
take to manage the drain? - CORRECT ANSWER-Compress the drain reservoir
after emptying.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving? - CORRECT
ANSWER-Glucose 272 mg/dL
A nurse is reviewing the laboratory findings of a client who developed chest pain
6 hr ago. The nurse should identify which of the following findings as an
indication of a myocardial infarction (MI)? - CORRECT ANSWER-Troponin I 8
ng/mL
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders
presents the greatest risk to this group of clients? - CORRECT
ANSWER-hypertension
A nurse is providing education to a client who is at risk for osteoporosis. Which of
the following instructions should the nurse include? - CORRECT ANSWER-Walk
for 30 min four times per week.
A nurse is caring for a client who has an arterial line. Which of the following
actions should the nurse take? - CORRECT ANSWER-Place a pressure bag
around the flush solution.
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A nurse is reviewing the ABG results of a client who has advanced COPD. Which
of the following results should the nurse expect? - CORRECT ANSWER-PaCO2
56
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
CORRECT ANSWER-Flex the foot every hour when awake.
A nurse is planning care for a client who is postoperative following a
parathyroidectomy. Which of the following actions should the nurse identify as the
priority? - CORRECT ANSWER-Place a tracheostomy tray at the bedside.
A nurse is evaluating the plan of care for four clients after 2 days of
hospitalization. The nurse should identify the need to revise the plan for which of
the following clients? - CORRECT ANSWER-A client who is postoperative
following abdominal surgery and reports feeling that something "popped" when
they coughed
A nurse is checking the ECG rhythm strip for a client who has a temporary
pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex.
Which of the following actions should the nurse take? - CORRECT
ANSWER-Document that depolarization has occurred.
A nurse is providing discharge instructions to a client who has active tuberculosis
(TB). Which of the following information should the nurse include in the
instructions? - CORRECT ANSWER-Sputum specimens are necessary every 2
to 4 weeks until there are three negative cultures.
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? - CORRECT
ANSWER-Slow the infusion rate
A nurse is assessing a client who is postoperative following a thyroidectomy.
Which of the following findings is the nurse's priority? - CORRECT
ANSWER-Temperature 38.9° C (102° F)
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A nurse is caring for a client who has homonymous hemianopsia as a result of a
stroke. To reduce the risk of falls when ambulating, the nurse should provide
which of the following instructions to the client? - CORRECT ANSWER-Scan the
environment by turning your head from side to side.
A PACU nurse is assessing a client who is postoperative following a right
nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure
130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.80 F). Which
of the following vital sign changes should alert the nurse that the client might be
hemorrhaging? - CORRECT ANSWER-Heart rate 110/min
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - CORRECT ANSWER-Scan the bladder with
a portable ultrasound.
A nurse is assessing a client who has advanced lung cancer and is receiving
palliative care. The client has just undergone thoracentesis. The nurse should
expect a reduction in which of the following common manifestations of advanced
cancer? - CORRECT ANSWER-Dyspnea
A nurse is caring for a client who is postoperative. - CORRECT
ANSWER-Nurses' Notes
Client admitted to medical-surgical unit from PACU. Client reports incisional pain
as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water.
Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for
the past 2 hr. Moderate amount of bright red drainage noted on surgical incision
dressing.
Vital Signs
Temperature 37.6° C (99.7° F)
Heart rate 114/min
Respiratory rate 22/min
Blood pressure 88/54 mm Hg
Oxygen saturation 93% on room air
Diagnostic Results
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Hgb 18 g/dL (12 to 16 g/dL)
Hct 54% (37% to 47 %)
Total WBC count 11,000/mm3 (5,000 to 10,000/mm3)
Troponin T 0.04 ng/mL (less than 0.1 ng/mL)
Medical History.
History of hypertension. Acute myocardial infarction 1 year ago.
Complete the diagram by dragging from the choices below to specify what
condition the client is most likely experiencing, two actions the nurse should take
to address that condition, and two parameters the nurse should monitor to
assess the client's progress. - CORRECT ANSWER-The nurse should insert a
large-gauge IV and initiate a fluid challenge because the client is most likely
experiencing hypovolemia as evidenced by the client's restlessness, tachycardia,
hypotension, decreased pulses, cool extremities, and decreased urine output.
The nurse should monitor the client's urine output and blood pressure to evaluate
the effectiveness of treatment.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - CORRECT ANSWER-Change
position every hour
A nurse is performing a preoperative assessment for a client. The nurse should
identify that an allergy to which of the following foods can indicate a latex allergy?
- CORRECT ANSWER-avocados
- CORRECT ANSWER-Vital Signs
Blood pressure 155/98 mm Hg
Heart rate 98/min
Respiratory rate 14/min
Temperature 38.4° C (101.1 ° F)
Medication Administration Record
Gentamicin 60 mg intermittent IV bolus Q8H
Ceftriaxone 1 g intermittent IV bolus BID
Morphine 2.5 mg IV bolus Q3H PRN for pain
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