ATI MED SURG PROCTORED WITH NGN 2026-2027 LATEST
ACTUAL EXAM ALL QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+.
A nurse is caring for a client who experienced a traumatic head injury and has
an intraventricular catheter (ventriculostomy) for intracranial pressure (ICP)
monitoring. The nurse should monitor the client for which of the following
complications related to the ventriculostomy?
A) Headache
B) Infection
C) Aphasia
D) Hypertension
Correct Answer: B
Rationale
An intraventricular catheter (ventriculostomy) is an invasive monitoring device
inserted into the lateral ventricle of the brain to continuously measure
intracranial pressure and allow for cerebrospinal fluid (CSF) drainage. The
primary complication associated with ventriculostomy is infection, particularly
meningitis or ventriculitis, because the catheter provides a direct pathway for
microorganisms to enter the central nervous system. The nurse must maintain
strict aseptic technique during all aspects of care, including insertion, dressing
changes, and CSF sampling. Other complications include hemorrhage,
catheter obstruction, and malpositioning. Headache may occur but is not a
specific complication of the device. Aphasia is a neurological deficit related to
the head injury itself, not the ventriculostomy. Hypertension may be a
manifestation of increased ICP but is not a complication of the monitoring
device. The nurse should monitor for signs of infection, including fever, nuchal
rigidity, altered mental status, and changes in CSF appearance.
,A nurse is providing education to a client who is to undergo an
electroencephalogram (EEG) the next day. Which of the following information
should the nurse include in the teaching?
A) "Do not wash your hair the morning of the procedure."
B) "Try to stay awake most of the night prior to the procedure."
C) "The procedure will take approximately 15 minutes."
D) "You will need to lie flat for 4 hours after the procedure."
Correct Answer: B
Rationale
The nurse should instruct the client to remain awake most of the night prior
to the EEG to induce sleep deprivation, which increases cranial stress and the
likelihood of abnormal electrical activity being captured during the study.
Sleep deprivation is a common technique used to provoke seizure activity or
other abnormalities in clients with suspected seizure disorders. Option A is
incorrect because the client should wash their hair the morning of the
procedure to remove oils and hair products that can interfere with electrode
adherence. Option C is incorrect because an EEG typically takes 45 to 60
minutes, not 15 minutes. Option D is incorrect because lying flat for 4 hours is
required after a lumbar puncture, not an EEG. The nurse should also instruct
the client to avoid caffeine and other stimulants before the procedure and to
take any prescribed medications unless otherwise directed.
A nurse is caring for a client who is postprocedural following a lumbar
puncture and reports a throbbing headache when sitting upright. Which of
the following actions should the nurse take? (Select all that apply.)
A) Use the Glasgow Coma Scale to assess the client
B) Assist the client into a supine position
C) Administer an opioid analgesic
D) Encourage the client to increase oral fluid intake
E) Instruct the client to perform coughing and deep breathing exercises
Correct Answers: B, D
,Rationale
B) Assist the client into a supine position is correct. A post-lumbar puncture
headache is caused by leakage of cerebrospinal fluid (CSF) from the puncture
site, leading to decreased CSF pressure and traction on the meninges.
Positioning the client supine (flat) reduces the traction and alleviates the
headache.
D) Encourage the client to increase oral fluid intake is correct. Increased fluid
intake helps restore CSF volume and pressure, which can relieve the
headache.
A) Use the Glasgow Coma Scale to assess the client is incorrect. The GCS is
used to assess neurological status in clients with head injuries or altered
consciousness; it is not indicated for a post-lumbar puncture headache.
C) Administer an opioid analgesic is incorrect. While the headache may be
painful, the priority interventions are positioning and hydration; caffeine may
also be prescribed. Opioids may mask symptoms and are not the first-line
treatment.
E) Instruct the client to perform coughing and deep breathing exercises is
incorrect. Coughing and straining increase intracranial pressure and may
worsen the headache.
A nurse is caring for a client who has continuous bladder irrigation following a
transurethral resection of the prostate (TURP). Which of the following findings
should the nurse report to the provider?
A) Output equal to the instilled irrigant
B) Client reports bladder spasms
C) Viscous urinary output with clots
D) Reports of a strong urge to urinate
Correct Answer: C
Rationale
Viscous urinary output with large clots is an indication of arterial bleeding and
should be reported to the provider immediately. After a TURP, the client
should have pink to light red urine with small clots. Bright red urine with large,
viscous clots indicates active bleeding that may require intervention. Option
, A, output equal to the instilled irrigant, is an expected finding that indicates
the catheter is patent and there is no obstruction. Option B, bladder spasms,
is a common postoperative finding and can be managed with antispasmodic
medications. Option D, a strong urge to urinate, is expected due to the
presence of the urinary catheter and bladder irritation. The nurse should
monitor the color and consistency of the urinary output, document the
amount of irrigant used and output, and assess for signs of bleeding or
obstruction.
A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the
following findings should the nurse expect?
A) Flattened T waves
B) Prolonged QT intervals
C) Shortened QT intervals
D) Widened QRS complexes
Correct Answer: B
Rationale
Hypocalcemia (decreased serum calcium levels) prolongs the QT interval on
the ECG because calcium is essential for myocardial depolarization and
repolarization. Prolonged QT intervals increase the risk of life-threatening
dysrhythmias such as torsades de pointes. Other manifestations of
hypocalcemia include tingling (paresthesia), numbness, muscle cramps,
tetany, Chvostek's sign, Trousseau's sign, and laryngospasm. Option A,
flattened T waves, is associated with hypokalemia. Option C, shortened QT
intervals, is associated with hypercalcemia. Option D, widened QRS
complexes, is associated with hyperkalemia or bundle branch blocks. The
nurse should monitor the client's calcium levels, ECG, and signs of
neuromuscular irritability, and report prolonged QT intervals to the provider.
A nurse is preparing a client who has a brain tumor for a CT scan. Which of the
following factors affects the manner in which the nurse will prepare the client
for the scan?
ACTUAL EXAM ALL QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+.
A nurse is caring for a client who experienced a traumatic head injury and has
an intraventricular catheter (ventriculostomy) for intracranial pressure (ICP)
monitoring. The nurse should monitor the client for which of the following
complications related to the ventriculostomy?
A) Headache
B) Infection
C) Aphasia
D) Hypertension
Correct Answer: B
Rationale
An intraventricular catheter (ventriculostomy) is an invasive monitoring device
inserted into the lateral ventricle of the brain to continuously measure
intracranial pressure and allow for cerebrospinal fluid (CSF) drainage. The
primary complication associated with ventriculostomy is infection, particularly
meningitis or ventriculitis, because the catheter provides a direct pathway for
microorganisms to enter the central nervous system. The nurse must maintain
strict aseptic technique during all aspects of care, including insertion, dressing
changes, and CSF sampling. Other complications include hemorrhage,
catheter obstruction, and malpositioning. Headache may occur but is not a
specific complication of the device. Aphasia is a neurological deficit related to
the head injury itself, not the ventriculostomy. Hypertension may be a
manifestation of increased ICP but is not a complication of the monitoring
device. The nurse should monitor for signs of infection, including fever, nuchal
rigidity, altered mental status, and changes in CSF appearance.
,A nurse is providing education to a client who is to undergo an
electroencephalogram (EEG) the next day. Which of the following information
should the nurse include in the teaching?
A) "Do not wash your hair the morning of the procedure."
B) "Try to stay awake most of the night prior to the procedure."
C) "The procedure will take approximately 15 minutes."
D) "You will need to lie flat for 4 hours after the procedure."
Correct Answer: B
Rationale
The nurse should instruct the client to remain awake most of the night prior
to the EEG to induce sleep deprivation, which increases cranial stress and the
likelihood of abnormal electrical activity being captured during the study.
Sleep deprivation is a common technique used to provoke seizure activity or
other abnormalities in clients with suspected seizure disorders. Option A is
incorrect because the client should wash their hair the morning of the
procedure to remove oils and hair products that can interfere with electrode
adherence. Option C is incorrect because an EEG typically takes 45 to 60
minutes, not 15 minutes. Option D is incorrect because lying flat for 4 hours is
required after a lumbar puncture, not an EEG. The nurse should also instruct
the client to avoid caffeine and other stimulants before the procedure and to
take any prescribed medications unless otherwise directed.
A nurse is caring for a client who is postprocedural following a lumbar
puncture and reports a throbbing headache when sitting upright. Which of
the following actions should the nurse take? (Select all that apply.)
A) Use the Glasgow Coma Scale to assess the client
B) Assist the client into a supine position
C) Administer an opioid analgesic
D) Encourage the client to increase oral fluid intake
E) Instruct the client to perform coughing and deep breathing exercises
Correct Answers: B, D
,Rationale
B) Assist the client into a supine position is correct. A post-lumbar puncture
headache is caused by leakage of cerebrospinal fluid (CSF) from the puncture
site, leading to decreased CSF pressure and traction on the meninges.
Positioning the client supine (flat) reduces the traction and alleviates the
headache.
D) Encourage the client to increase oral fluid intake is correct. Increased fluid
intake helps restore CSF volume and pressure, which can relieve the
headache.
A) Use the Glasgow Coma Scale to assess the client is incorrect. The GCS is
used to assess neurological status in clients with head injuries or altered
consciousness; it is not indicated for a post-lumbar puncture headache.
C) Administer an opioid analgesic is incorrect. While the headache may be
painful, the priority interventions are positioning and hydration; caffeine may
also be prescribed. Opioids may mask symptoms and are not the first-line
treatment.
E) Instruct the client to perform coughing and deep breathing exercises is
incorrect. Coughing and straining increase intracranial pressure and may
worsen the headache.
A nurse is caring for a client who has continuous bladder irrigation following a
transurethral resection of the prostate (TURP). Which of the following findings
should the nurse report to the provider?
A) Output equal to the instilled irrigant
B) Client reports bladder spasms
C) Viscous urinary output with clots
D) Reports of a strong urge to urinate
Correct Answer: C
Rationale
Viscous urinary output with large clots is an indication of arterial bleeding and
should be reported to the provider immediately. After a TURP, the client
should have pink to light red urine with small clots. Bright red urine with large,
viscous clots indicates active bleeding that may require intervention. Option
, A, output equal to the instilled irrigant, is an expected finding that indicates
the catheter is patent and there is no obstruction. Option B, bladder spasms,
is a common postoperative finding and can be managed with antispasmodic
medications. Option D, a strong urge to urinate, is expected due to the
presence of the urinary catheter and bladder irritation. The nurse should
monitor the color and consistency of the urinary output, document the
amount of irrigant used and output, and assess for signs of bleeding or
obstruction.
A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the
following findings should the nurse expect?
A) Flattened T waves
B) Prolonged QT intervals
C) Shortened QT intervals
D) Widened QRS complexes
Correct Answer: B
Rationale
Hypocalcemia (decreased serum calcium levels) prolongs the QT interval on
the ECG because calcium is essential for myocardial depolarization and
repolarization. Prolonged QT intervals increase the risk of life-threatening
dysrhythmias such as torsades de pointes. Other manifestations of
hypocalcemia include tingling (paresthesia), numbness, muscle cramps,
tetany, Chvostek's sign, Trousseau's sign, and laryngospasm. Option A,
flattened T waves, is associated with hypokalemia. Option C, shortened QT
intervals, is associated with hypercalcemia. Option D, widened QRS
complexes, is associated with hyperkalemia or bundle branch blocks. The
nurse should monitor the client's calcium levels, ECG, and signs of
neuromuscular irritability, and report prolonged QT intervals to the provider.
A nurse is preparing a client who has a brain tumor for a CT scan. Which of the
following factors affects the manner in which the nurse will prepare the client
for the scan?
