ATI Med-Surg Proctored Exam Practice Questions
and Answers 100% Verified
Question:
A charge nurse is observing a newly licensed nurse administer an IV medication to a client
who has an implanted venous access port. Which of the following observations requires
intervention by the charge nurse? A. A dressing is not applied to the port site after use. B. A
22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to
administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been
prepared.
Answer:
D. A solution of 5 mL heparin 1,000 units/mL has been prepared. Implanted ports should
be flushed after each use and at least once a month when not in use. This practice is
sometimes referred to as "locking" or "de-accessing." It is performed to prevent the
formation of blood clots in the catheter, which would disrupt the proper functioning of the
catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action
requires intervention by the charge nurse.
Question:
A client is being discharged home with oxygen therapy delivered through a nasal cannula.
Which of the following instructions should the nurse provide to the client and family
members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to
protect the facial skin from irritation. C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity.
Answer:
D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the
buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in
high concentrations has great combustion potential and readily fuels fire. Although it will
not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room
if it contacts a spark.
,Question:
An emergency room nurse is assessing a client who has a new traumatic brain injury. The
nurse observes extension of the client's arms and legs, pronation of the arms, and plantar
flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary
output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure
precautions
Answer:
C. Provide supplemental oxygen The first action the nurse should take when using the
airway, breathing, and circulation (ABC) approach to client care is to provide
supplemental oxygen. The client might require an artificial airway and mechanical
ventilation because these findings indicate decerebrate positioning, which is associated
with brainstem injury and can lead to brain herniation and death.
Question:
A nurse in an emergency department is assessing a client who sustained a fall off of a roof.
Which of the following findings should the nurse identify as an indication of a basilar skull
fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C.
Motor loss on one side of the body D. Bleeding from the top of the scalp
Answer:
B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming
from the nares or ears, indicating a basilar skull fracture.
, Question:
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which
of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh
B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
Answer:
C. Chest petechiae The nurse should identify chest petechiae as an indication of fat
embolism syndrome. Clients who have fractures of the long bones such as the femur are
at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury
when fat droplets from the marrow enter into the systemic circulation and are deposited
in the lungs. The nurse should immediately notify the provider because the client could
progress to acute respiratory failure.
Question:
A nurse is assessing a client who has cholecystitis. Which of the following findings should
the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign
Answer:
A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's
sign) in a client who has cholecystitis. This response can be an indication of peritoneal
inflammation. :B. The nurse should expect to find ascites in a client who has chronic
pancreatitis or pancreatic cancer. C. The nurse should expect to find gastrointestinal
bleeding in a client who has pancreatic cancer. D. The nurse should expect to find a
positive Kehr's sign in a client who has liver trauma.
and Answers 100% Verified
Question:
A charge nurse is observing a newly licensed nurse administer an IV medication to a client
who has an implanted venous access port. Which of the following observations requires
intervention by the charge nurse? A. A dressing is not applied to the port site after use. B. A
22-gauge non-coring needle is used to access the port. C. Blood return is noted prior to
administering the medication. D. A solution of 5 mL heparin 1,000 units/mL has been
prepared.
Answer:
D. A solution of 5 mL heparin 1,000 units/mL has been prepared. Implanted ports should
be flushed after each use and at least once a month when not in use. This practice is
sometimes referred to as "locking" or "de-accessing." It is performed to prevent the
formation of blood clots in the catheter, which would disrupt the proper functioning of the
catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action
requires intervention by the charge nurse.
Question:
A client is being discharged home with oxygen therapy delivered through a nasal cannula.
Which of the following instructions should the nurse provide to the client and family
members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to
protect the facial skin from irritation. C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity.
Answer:
D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the
buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in
high concentrations has great combustion potential and readily fuels fire. Although it will
not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room
if it contacts a spark.
,Question:
An emergency room nurse is assessing a client who has a new traumatic brain injury. The
nurse observes extension of the client's arms and legs, pronation of the arms, and plantar
flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary
output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure
precautions
Answer:
C. Provide supplemental oxygen The first action the nurse should take when using the
airway, breathing, and circulation (ABC) approach to client care is to provide
supplemental oxygen. The client might require an artificial airway and mechanical
ventilation because these findings indicate decerebrate positioning, which is associated
with brainstem injury and can lead to brain herniation and death.
Question:
A nurse in an emergency department is assessing a client who sustained a fall off of a roof.
Which of the following findings should the nurse identify as an indication of a basilar skull
fracture? A. Depressed fracture of the forehead B. Clear fluid coming from the nares C.
Motor loss on one side of the body D. Bleeding from the top of the scalp
Answer:
B. Clear fluid coming from the nares Cerebrospinal fluid manifests as a clear fluid coming
from the nares or ears, indicating a basilar skull fracture.
, Question:
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which
of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh
B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
Answer:
C. Chest petechiae The nurse should identify chest petechiae as an indication of fat
embolism syndrome. Clients who have fractures of the long bones such as the femur are
at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury
when fat droplets from the marrow enter into the systemic circulation and are deposited
in the lungs. The nurse should immediately notify the provider because the client could
progress to acute respiratory failure.
Question:
A nurse is assessing a client who has cholecystitis. Which of the following findings should
the nurse expect? A. Blumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign
Answer:
A. Blumberg's sign The nurse should expect to find rebound tenderness (Blumberg's
sign) in a client who has cholecystitis. This response can be an indication of peritoneal
inflammation. :B. The nurse should expect to find ascites in a client who has chronic
pancreatitis or pancreatic cancer. C. The nurse should expect to find gastrointestinal
bleeding in a client who has pancreatic cancer. D. The nurse should expect to find a
positive Kehr's sign in a client who has liver trauma.
