MED SURG- PROCTORED ATI | [LATEST 2026/2027 UPDATE] QUESTIONS & ANSWERS | GRADE A | 100% CORRECT
An older adult is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse
to suspect that the client has hypertonic dehydration? ✔️Urine Specific gravity 1.045
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of
hypertonic dehydration.
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for
migraine headaches, which of the following foods should the nurse recommend the client avoid? ✔️Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy.
Which of the following statements should the nurse include in the teaching? ✔️"You should cut the opening of the skin barrier one-eight inch
wider than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to minimize irritation of the skin from exposure to
urine.
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which
of the following supplements can interfere with the effectiveness of the medication? ✔️Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere
with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4
hr of levothyroxine administration.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that
which of the following findings requires further assessment? ✔️History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can
result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a
component of Cushing's triad? ✔️Bradycardia
A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's
triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should
the nurse take? ✔️Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi)
when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg.
Which of the following prescriptions should the expect? ✔️Administer an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
,A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to
the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client). ✔️Current medications
The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline,
nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's
reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin
testing.
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions
should the nurse take? ✔️Inject the medication into the anterolateral abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent
hematoma formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the following findings contribute to delayed wound healing? ✔️Urine
output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN
solution has 500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the nearest whole number.) ✔️167 mL/hr
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 cabbage to the diet.
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 has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate
the client for which of the following laboratory findings? ✔️Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is teaching a client with systemic erythematosus who has a new prescription for prednisone. The nurse should instruct the client to
monitor for which of the following adverse effects of this medication? ✔️Infection
The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a
sore throat. Prednisone can suppress the client's immune response and mask the manifestations of an infection.
A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that
the client understands the impact of the surgery? ✔️"I understand that I will have a permanent tracheostomy after the surgery."
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent.
A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? ✔️Finger contractures
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2
types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs.
Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma the
body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues
, becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma
unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.
A nurse is caring for a client who has tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator
sounds, it indicates which of the following to the nurse? ✔️A leak within the ventilator's circuitry
The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are
often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the
ventilator.
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the
nurse expect? ✔️Involuntary muscle spasms
The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are
damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and
calcium deficiency.
A nurse is providing discharge teaching to client who has osteoarthritis. Which of the following instructions should the nurse include? ✔️"Rest
frequently after periods of activity."
The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve
the pain, so performing activities at a comfortable pace with periods of rest is appropriate.
A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the
nurse include? ✔️"Apply heat to your joints prior to exercising."
The nurse should instruct the client to apply heat to the joints prior to exercising to increase mobility and reduce pain.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical
therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump the nurse should monitor
the client for which of the following findings? ✔️Diaphoresis
The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In
addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? ✔️Lower
back discomfort
An abdominal aortic aneurysm involves widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the
aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following
laboratory findings should the nurse expect? ✔️Sodium 132 mEq/L
This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in
interstitial space.
The normal sodium level is 135-145 mEq/L
A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates
the client is experiencing acute kidney rejection? ✔️Blood pressure 160/90 mmHg
An older adult is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse
to suspect that the client has hypertonic dehydration? ✔️Urine Specific gravity 1.045
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of
hypertonic dehydration.
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for
migraine headaches, which of the following foods should the nurse recommend the client avoid? ✔️Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy.
Which of the following statements should the nurse include in the teaching? ✔️"You should cut the opening of the skin barrier one-eight inch
wider than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to minimize irritation of the skin from exposure to
urine.
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which
of the following supplements can interfere with the effectiveness of the medication? ✔️Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere
with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4
hr of levothyroxine administration.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that
which of the following findings requires further assessment? ✔️History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can
result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a
component of Cushing's triad? ✔️Bradycardia
A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's
triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should
the nurse take? ✔️Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi)
when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg.
Which of the following prescriptions should the expect? ✔️Administer an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
,A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to
the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client). ✔️Current medications
The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline,
nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's
reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin
testing.
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions
should the nurse take? ✔️Inject the medication into the anterolateral abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent
hematoma formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the following findings contribute to delayed wound healing? ✔️Urine
output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN
solution has 500kcal/L. The IV pump should be set at how many mL/hr? (Rounding to the nearest whole number.) ✔️167 mL/hr
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 cabbage to the diet.
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 has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate
the client for which of the following laboratory findings? ✔️Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine.
A nurse is teaching a client with systemic erythematosus who has a new prescription for prednisone. The nurse should instruct the client to
monitor for which of the following adverse effects of this medication? ✔️Infection
The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a
sore throat. Prednisone can suppress the client's immune response and mask the manifestations of an infection.
A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that
the client understands the impact of the surgery? ✔️"I understand that I will have a permanent tracheostomy after the surgery."
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryngectomy, so the tracheostomy will be permanent.
A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect? ✔️Finger contractures
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. There are 2
types of scleroderma: localized scleroderma, which mainly affects the skin, and systemic scleroderma, which can affect internal organs.
Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dry mucous membranes. With scleroderma the
body produces and deposits too much collagen, causing thickening and hardening. In addition to the client's skin and subcutaneous tissues
, becoming increasingly hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma
unless clients follow a regimen of range-of-motion and muscle-strengthening exercises.
A nurse is caring for a client who has tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator
sounds, it indicates which of the following to the nurse? ✔️A leak within the ventilator's circuitry
The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are
often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the
ventilator.
A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the
nurse expect? ✔️Involuntary muscle spasms
The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are
damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and
calcium deficiency.
A nurse is providing discharge teaching to client who has osteoarthritis. Which of the following instructions should the nurse include? ✔️"Rest
frequently after periods of activity."
The joint pain in osteoarthritis is caused by deterioration of the synovial membranes and often worsens after activity. Rest usually helps relieve
the pain, so performing activities at a comfortable pace with periods of rest is appropriate.
A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the
nurse include? ✔️"Apply heat to your joints prior to exercising."
The nurse should instruct the client to apply heat to the joints prior to exercising to increase mobility and reduce pain.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical
therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump the nurse should monitor
the client for which of the following findings? ✔️Diaphoresis
The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In
addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? ✔️Lower
back discomfort
An abdominal aortic aneurysm involves widening, stretching, or ballooning of the aorta. Back pain and abdominal pain indicate that the
aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following
laboratory findings should the nurse expect? ✔️Sodium 132 mEq/L
This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in
interstitial space.
The normal sodium level is 135-145 mEq/L
A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates
the client is experiencing acute kidney rejection? ✔️Blood pressure 160/90 mmHg
