ATI PN MEDICAL-SURGICAL- FINAL
EXAM 2023/2024 (VERIFIED VERSION)
EXPERT ANSWERS WITH RATIONALES
100% REAL EXAM GUARANTEED PASS
A nurse is caring for a client who is to have his chest tube removed. Which fo the
following actions should the nurse take?
- Cover the insertion site with a hydrocolloid dressing after removal.
- Provide pain medication immediately after removal.
- Instruct the client to perform the Valsalva maneuver during removal.
- Delegate removal of the chest tube to a licensed practical nurse (LPN).
Instruct the client to perform the Valsalva maneuver during removal.
The nurse should instruct the client to perform the Valsalva maneuver during
removal to maintain the appropriate amount of negative pressure in the chest to
prevent air entry into the pleural space.
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting
in a chair at the bedside. Which of the following actions should the nurse take
first?
- Provide oxygen.
- Place the client in a side-lying position.
- Provide privacy.
- Lower the client to the floor.
Lower the client to the floor.
The nurse should apply the safety and risk reduction priority-setting framework.
This framework assigns priority to the factor or situation posing the greatest safety
risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow's hierarchy of
needs, the ABC priority-setting framework, or nursing knowledge to identify
,which risk poses the greatest threat to the client. Therefore, if a client begins to
have a seizure while sitting or standing, the nurse should first lower the client to
the floor to protect him from injury.
A nurse is teaching a client how to perform a breast self-exam (BSE). The nurse
should identify which of the following findings as an indication of breast cancer?
- Lumps that are mobile and tender upon palpation prior to a menstrual period
- Multiple round masses that are tender and found in both breasts
- Bilaterally darkened areolas
- A nontender, hard lump that is palpated in one breast
A nontender, hard lump that is palpated in one breast
The nurse should identify that cancerous tumors are typically hard, fixed, irregular
in shape, and nontender to palpation. The nurse should instruct the client to notify
the provider promptly if she palpates a hard, nontender lump.
A nurse is preparing to change the bed linens of a client who has AIDS and is
incontinent of stool. Which of the following personal protective equipment (PPE)
should the nurse don prior to providing client care?
- Gown
- Gloves
- Mask
- Hair cover
- Goggles
- Gown
- Gloves
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?
- Ecchymosis of the thigh
- Serous drainage at the pin site
- Chest petechiae
- Muscle spasms in the left leg
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 for fat emboli. Fat emboli typically occur 12 to 48 hr 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 into acute respiratory failure.
A nurse is providing teaching about antiretroviral therapy to a client who has a new
diagnosis of AIDS. Which of the following statements should the nurse include in
the teaching?
- "Your provider will prescribe one single antiretroviral medication at a time."
- "You should take antiretroviral medications on a routine schedule."
- "You should increase your intake of raw fruits and vegetables while taking
antiretroviral medications."
- "Your provider will prescribe antiretroviral therapy to kill the HIV virus."
"You should take antiretroviral medications on a routine schedule."
The nurse should inform the client of the need to take antiretroviral therapy exactly
as prescribed and to avoid delaying or skipping any doses, which can result in
medication resistance.
A nurse is caring for a client who is 72 hr post operative following an above-the-
knee amputation. Which of the following actions should the nurse take?
- Elevate the residual limb on a soft pillow.
- Assist the client to a prone position every 4 hr.
- Reapply a bandage to the residual limb every 12 hr.
- Apply dressings to the site in a proximal-to-distal direction.
Assist the client to a prone position every 4 hr.
The nurse should assist the client to a prone position for 20 to 30 min every 3 to 4
hr following an amputation because it reduces the risk of flexion contractures.
A home health nurse enters a client's home and finds used insulin syringe, without
a cap, on the table. Which of the following actions should the nurse take?
- Recap the needle on the syringe.
- Schedule a nurse to administer future injections for this client.
- Explain to the client that the syringe should be disposed of in the bathroom trash
can.
- Place the syringe in a puncture-proof disposal container.
EXAM 2023/2024 (VERIFIED VERSION)
EXPERT ANSWERS WITH RATIONALES
100% REAL EXAM GUARANTEED PASS
A nurse is caring for a client who is to have his chest tube removed. Which fo the
following actions should the nurse take?
- Cover the insertion site with a hydrocolloid dressing after removal.
- Provide pain medication immediately after removal.
- Instruct the client to perform the Valsalva maneuver during removal.
- Delegate removal of the chest tube to a licensed practical nurse (LPN).
Instruct the client to perform the Valsalva maneuver during removal.
The nurse should instruct the client to perform the Valsalva maneuver during
removal to maintain the appropriate amount of negative pressure in the chest to
prevent air entry into the pleural space.
A nurse is caring for a client who begins having a tonic-clonic seizure while sitting
in a chair at the bedside. Which of the following actions should the nurse take
first?
- Provide oxygen.
- Place the client in a side-lying position.
- Provide privacy.
- Lower the client to the floor.
Lower the client to the floor.
The nurse should apply the safety and risk reduction priority-setting framework.
This framework assigns priority to the factor or situation posing the greatest safety
risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow's hierarchy of
needs, the ABC priority-setting framework, or nursing knowledge to identify
,which risk poses the greatest threat to the client. Therefore, if a client begins to
have a seizure while sitting or standing, the nurse should first lower the client to
the floor to protect him from injury.
A nurse is teaching a client how to perform a breast self-exam (BSE). The nurse
should identify which of the following findings as an indication of breast cancer?
- Lumps that are mobile and tender upon palpation prior to a menstrual period
- Multiple round masses that are tender and found in both breasts
- Bilaterally darkened areolas
- A nontender, hard lump that is palpated in one breast
A nontender, hard lump that is palpated in one breast
The nurse should identify that cancerous tumors are typically hard, fixed, irregular
in shape, and nontender to palpation. The nurse should instruct the client to notify
the provider promptly if she palpates a hard, nontender lump.
A nurse is preparing to change the bed linens of a client who has AIDS and is
incontinent of stool. Which of the following personal protective equipment (PPE)
should the nurse don prior to providing client care?
- Gown
- Gloves
- Mask
- Hair cover
- Goggles
- Gown
- Gloves
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?
- Ecchymosis of the thigh
- Serous drainage at the pin site
- Chest petechiae
- Muscle spasms in the left leg
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 for fat emboli. Fat emboli typically occur 12 to 48 hr 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 into acute respiratory failure.
A nurse is providing teaching about antiretroviral therapy to a client who has a new
diagnosis of AIDS. Which of the following statements should the nurse include in
the teaching?
- "Your provider will prescribe one single antiretroviral medication at a time."
- "You should take antiretroviral medications on a routine schedule."
- "You should increase your intake of raw fruits and vegetables while taking
antiretroviral medications."
- "Your provider will prescribe antiretroviral therapy to kill the HIV virus."
"You should take antiretroviral medications on a routine schedule."
The nurse should inform the client of the need to take antiretroviral therapy exactly
as prescribed and to avoid delaying or skipping any doses, which can result in
medication resistance.
A nurse is caring for a client who is 72 hr post operative following an above-the-
knee amputation. Which of the following actions should the nurse take?
- Elevate the residual limb on a soft pillow.
- Assist the client to a prone position every 4 hr.
- Reapply a bandage to the residual limb every 12 hr.
- Apply dressings to the site in a proximal-to-distal direction.
Assist the client to a prone position every 4 hr.
The nurse should assist the client to a prone position for 20 to 30 min every 3 to 4
hr following an amputation because it reduces the risk of flexion contractures.
A home health nurse enters a client's home and finds used insulin syringe, without
a cap, on the table. Which of the following actions should the nurse take?
- Recap the needle on the syringe.
- Schedule a nurse to administer future injections for this client.
- Explain to the client that the syringe should be disposed of in the bathroom trash
can.
- Place the syringe in a puncture-proof disposal container.
