ATI Med-Surg Exam 2 (3 Versions) 2023/2024 Graded
A+
Exam 2 Version 1
1. A client who experienced a stroke on the left side of the brain suddenly begins to get angry and
frustrated while playing a card game. What is the best action by the rehabilitation nurse?
a. Reassure the client that there is nothing to be angry about
b. Ask the client what made him or her angry
c. Ask the client to stop behaving inappropriately
d. Distract the client
2. Admission vital signs for a brain-injured client are blood pressure 128/68 mm Hg, pulse of 110
BPM, and respirations of 26. Which set of vital signs, if taken 1 hour after admission, will be of
the most concern to the nurse?
a. BP 154/68 mm Hg, Pulse 56 BPM, RR 12
b. BP 134/72 mm Hg, Pulse 90 BPM, RR 32
c. BP 110/70 mm Hg, Pulse 120 BPM, RR 32
d. BP 148/78 mm Hg, Pulse 112 BPM, RR 28
3. A client is at the emergency room with suspected spinal cord and head injuries has a Glasgow
Coma scale of 15; blood pressure 133/84 mm Hg, pulse of 102 bpm, RR 19 and temperature
of 98F (36.6C). What is the most important nursing intervention during the initial care of the
client ?
a. Avoid moving the client
b. Keep the head of the bed elevated 30 degrees
c. Check the extremities for range of motion
d. Turn the client to the side to avoid aspiration
Spinal precautions include BED REST, NO NECK FLEXION WITH A PILLOW OR ROLL, NO THORACIC OR
LUMBAR FLEXION WITH HOB ELEVATION/BED CONTROLS (REVERSE TRENDELENBURG IS
ACCEPTABLE). Rigid cervical collar or long spine board are used to prevent new or secondary spine injury
if there is unstable vertebrae or ligament damage.
4. A client with acute ischemic stroke is ordered to receive alteplase. The client weighs 160.6 lbs.
Based on standard alteplase administration for stroke, how many mL per hour will the nurse
run bolus?
a. 386
b. 1
c. 3864
d. 65.7
, 5. A client receiving cyclosporine must be taught which of the following?
a. It’s alright to continue working at a daycare
b. Report signs of dark urine and yellowing of the skin
c. Nausea is an expected side effect
d. Bruising is an expected side effect.
Cyclosporine main side effect is Nephrotoxicity. (PAGE 302)
6. A client is admitted to the critical care unit with a subdural hematoma. The nurse is assessing
the client’s GCS score. When assessing the client’s best motor response, which movement
would receive the lowest score?
a. Abnormal extension
b. Decorticate posturing
c. Withdrawing from pain
d. Localizing Pain
MOTOR RESPONSE
OBEYS COMMANDS – 6
LOCALIZES PAIN – 5
NORMAL FLEXION (WITHDRAWAL) – 4
ABNORMAL FLEXION (DECORTICATE POSTURING) – 3
EXTENSION (DECEBERATE) – 2
NONE – 1
7. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious
patient. During the procedure the client reaches over with his left hand and tries to remove the
noxious (anything adversely affecting client *PAIN) stimuli. How would the nurse document
this response?
a. Decorticate posturing
b. Localization
c. Decerebrate posturing
d. Withdrawal
8. A client with increased intracranial pressure is admitted to the intensive care unit. On admission,
the nurse determines the client’s Glasgow Coma Scale is 10. One hour later, the client’s score
is
13. Which interpretation would the nurse make?
, a. The client’s condition has improved
b. The client is ready for discharge
c. The client is comatose
d. The client’s condition is worsening
9. Prescribed: Heparin infusion at 30 mL/hr. The provided solution is 40,000 units heparin in 500 mL
D5W. How many units/hour will the client receive?
a. 40 B.
267
C. 2400
D. 16.67
10. A client with a serious head injury has been admitted. The nurse knows that certain neurologic
findings can indicate the prognosis for the client. Which finding denotes the most serious
prognosis?
a. Decorticate posturing (3 on GCS)
b. GCS score of 12 (15 is perfect)
c. Decerebrate posturing (2 on GCS)
d. Absence of Babinski reflex (NORMAL)
11. A client received a bone marrow transplant for treatment of leukemia after completing
chemotherapy and radiation. The client develops a severe generalized skin rash 10 days after
the transplant. The nurse recognizes this reaction is an indication of which of the following? a.
Donor T cells are attacking the client’s skin cells
b. Client will need treatment to prevent hyperacute rejection
c. Client’s antibodies are rejecting the donor bone marrow
d. Client is experiencing a delayed hypersensitivity reaction.
Tissues usually attacked in GVHD are the skin (maculopapular rash), eyes, intestinal system and GI tract.
May begin 7 to 30 days after transplantation.
12. A client is started on immunosuppressant drugs after kidney transplantation and will be taking
azathioprine as part of a drug regimen. The client asks the nurse why it is necessary to have a
specimen for a complete blood count drawn at the beginning of the therapy and then
periodically thereafter. The nurse explains that azathioprine can alter blood cells and tells the
client that it is most critical to report which of the following?
a. Easy bruising
b. Fatigue
c. Constipation
d. Alopecia
PAGE 302 – Side effects of Azathioprine include BONE MARROW SUPPRESSION AND
THROMBOCYTOPENIA
13. The nurse is caring for a severely head injured comatose client who is dying. The nurse knows
the client has entered the late stages of intracranial HTN when the nurse observes which signs?
A+
Exam 2 Version 1
1. A client who experienced a stroke on the left side of the brain suddenly begins to get angry and
frustrated while playing a card game. What is the best action by the rehabilitation nurse?
a. Reassure the client that there is nothing to be angry about
b. Ask the client what made him or her angry
c. Ask the client to stop behaving inappropriately
d. Distract the client
2. Admission vital signs for a brain-injured client are blood pressure 128/68 mm Hg, pulse of 110
BPM, and respirations of 26. Which set of vital signs, if taken 1 hour after admission, will be of
the most concern to the nurse?
a. BP 154/68 mm Hg, Pulse 56 BPM, RR 12
b. BP 134/72 mm Hg, Pulse 90 BPM, RR 32
c. BP 110/70 mm Hg, Pulse 120 BPM, RR 32
d. BP 148/78 mm Hg, Pulse 112 BPM, RR 28
3. A client is at the emergency room with suspected spinal cord and head injuries has a Glasgow
Coma scale of 15; blood pressure 133/84 mm Hg, pulse of 102 bpm, RR 19 and temperature
of 98F (36.6C). What is the most important nursing intervention during the initial care of the
client ?
a. Avoid moving the client
b. Keep the head of the bed elevated 30 degrees
c. Check the extremities for range of motion
d. Turn the client to the side to avoid aspiration
Spinal precautions include BED REST, NO NECK FLEXION WITH A PILLOW OR ROLL, NO THORACIC OR
LUMBAR FLEXION WITH HOB ELEVATION/BED CONTROLS (REVERSE TRENDELENBURG IS
ACCEPTABLE). Rigid cervical collar or long spine board are used to prevent new or secondary spine injury
if there is unstable vertebrae or ligament damage.
4. A client with acute ischemic stroke is ordered to receive alteplase. The client weighs 160.6 lbs.
Based on standard alteplase administration for stroke, how many mL per hour will the nurse
run bolus?
a. 386
b. 1
c. 3864
d. 65.7
, 5. A client receiving cyclosporine must be taught which of the following?
a. It’s alright to continue working at a daycare
b. Report signs of dark urine and yellowing of the skin
c. Nausea is an expected side effect
d. Bruising is an expected side effect.
Cyclosporine main side effect is Nephrotoxicity. (PAGE 302)
6. A client is admitted to the critical care unit with a subdural hematoma. The nurse is assessing
the client’s GCS score. When assessing the client’s best motor response, which movement
would receive the lowest score?
a. Abnormal extension
b. Decorticate posturing
c. Withdrawing from pain
d. Localizing Pain
MOTOR RESPONSE
OBEYS COMMANDS – 6
LOCALIZES PAIN – 5
NORMAL FLEXION (WITHDRAWAL) – 4
ABNORMAL FLEXION (DECORTICATE POSTURING) – 3
EXTENSION (DECEBERATE) – 2
NONE – 1
7. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious
patient. During the procedure the client reaches over with his left hand and tries to remove the
noxious (anything adversely affecting client *PAIN) stimuli. How would the nurse document
this response?
a. Decorticate posturing
b. Localization
c. Decerebrate posturing
d. Withdrawal
8. A client with increased intracranial pressure is admitted to the intensive care unit. On admission,
the nurse determines the client’s Glasgow Coma Scale is 10. One hour later, the client’s score
is
13. Which interpretation would the nurse make?
, a. The client’s condition has improved
b. The client is ready for discharge
c. The client is comatose
d. The client’s condition is worsening
9. Prescribed: Heparin infusion at 30 mL/hr. The provided solution is 40,000 units heparin in 500 mL
D5W. How many units/hour will the client receive?
a. 40 B.
267
C. 2400
D. 16.67
10. A client with a serious head injury has been admitted. The nurse knows that certain neurologic
findings can indicate the prognosis for the client. Which finding denotes the most serious
prognosis?
a. Decorticate posturing (3 on GCS)
b. GCS score of 12 (15 is perfect)
c. Decerebrate posturing (2 on GCS)
d. Absence of Babinski reflex (NORMAL)
11. A client received a bone marrow transplant for treatment of leukemia after completing
chemotherapy and radiation. The client develops a severe generalized skin rash 10 days after
the transplant. The nurse recognizes this reaction is an indication of which of the following? a.
Donor T cells are attacking the client’s skin cells
b. Client will need treatment to prevent hyperacute rejection
c. Client’s antibodies are rejecting the donor bone marrow
d. Client is experiencing a delayed hypersensitivity reaction.
Tissues usually attacked in GVHD are the skin (maculopapular rash), eyes, intestinal system and GI tract.
May begin 7 to 30 days after transplantation.
12. A client is started on immunosuppressant drugs after kidney transplantation and will be taking
azathioprine as part of a drug regimen. The client asks the nurse why it is necessary to have a
specimen for a complete blood count drawn at the beginning of the therapy and then
periodically thereafter. The nurse explains that azathioprine can alter blood cells and tells the
client that it is most critical to report which of the following?
a. Easy bruising
b. Fatigue
c. Constipation
d. Alopecia
PAGE 302 – Side effects of Azathioprine include BONE MARROW SUPPRESSION AND
THROMBOCYTOPENIA
13. The nurse is caring for a severely head injured comatose client who is dying. The nurse knows
the client has entered the late stages of intracranial HTN when the nurse observes which signs?
