ATI RN ADULT MEDICAL SURGICAL PROCTORED RETAKE EXAM

A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? A. Capillary refill less than 2 seconds B. Bounding distal pulses C. Intense pain with movement d. Erythema of the toes - C. Intense pain with movement A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a haemolytic transfusion reaction? A. Chills B. Hypertension C. Bradycardia D. Back pain - A. Chills A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? A. Remove the wedge device when turning B. Place two bed pillows between the legs when in bed C. Encourage the client to lean forward when attempting to stand D. Elevate the knees higher than the hips when sitting - B. Place two bed pillows between the legs when in bed A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances A. Povidone-iodine B. Adhesive tape C. Latex D. Anesthetics - C. Latex A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? A. Place hands on the upper abdomen during inhalation. B. Position the mouthpiece 2.5 cm (1 in) from the mouth C. Exhale slowly through pursed lips D. Hold breaths about 3 to 5 seconds before exhaling - D. Hold breaths about 3 to 5 seconds before exhaling A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? A. Check the clients hand grasps B. Administer an IV potassium drip C. Listen to the client's bowel sounds D. Initiate cardiac monitoring for the clients - D. Initiate cardiac monitoring for the clients A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? A. Chill the dialysate before administration B. Hang the drainage bag below the client's abdomen C. Place the client in high-Fowlers position D. Use clean technique to access the catheter - B. Hang the drainage bag below the client's abdomen A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? A. Inability to smell B. loss of peripheral vision C. Disequilibrium with movement D. Deviation of the tongue from midline - C. Disequilibrium with movement A nurse is planning care for a client who is one day postoperative Following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? A. Place pillows under the clients knees B. Avoid use of anticoagulants C. Discourage leg exercises while in bed D. apply compression stockings to the lower extremities - D. apply compression stockings to the lower extremities A nurse is providing a discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? A. "I will keep my left arm flexed at the elbow as much as possible" ? B. " I should expect less than 25 mL of secretions per day in the drainage devices " C. "I will perform strength building arm exercises using a 15 pound weight" D. " I will have to wait 2 months before additional saltine can be added to my breast expander" - B. " I should expect less than 25 mL of secretions per day in the drainage devices A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include I the first teaching? A. "Do not shake your inhaler before use" B. "Exhale Fully before bringing the inhaler to your lips " C. "Use Peroxide to clean the mouthpiece of your inhaler" D. "Depress the canister after you inhale" - B. "Exhale Fully before bringing the inhaler to your lips " A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider? A. Calcium level 11.5 mg/dL B. Serum albumin level 3.9g/dl C. Output 200 mL more than intake over the past 12 hr. D. Fasting blood glucose level 105 mg/dL - A. Calcium level 11.5 mg/dL A nurse is setting up a sterile field before preforming a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply) A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap B. Open the first flap of the sterile package toward the nurse's body C. Place a surgical pack with a sterile drape on the work surface D. Select a work surface at the nurse's waist level E. Apply sterile gloves before opening the pack - a, b, c A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? A. Obtain consent for surgery B. Insert an indwelling urinary catheter C. Insert an NG tube D. Apply antiembolic stoking's - D. Apply antiembolic stoking's A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the first sign of deteriorating neurological status? A. Pupillary dilation B. Cheyne-Strokes respirations C. Decorticate posturing D. Altered level of Consciousness - D. Altered level of Consciousness A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma? A. Flat lesion with irregular borders B. Raised lesion with a rolled border C. Scaly lesion with the crusted appearance D. Reddened lesion with dilated blood vessels - A. Flat lesion with irregular borders A nurse is caring for a client who has diabetes insipidus. Which Of the following medications should the nurse plan to administer. A. Lithium B. Desmopressin C. Regular insulin D. Furosemide - B. Desmopressin A nurse is preparing to assist with the insertion of a non-tunneled Central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take. A. Cleanse the site with a hydrogen peroxide solution B. instruct the client to cough as the catheter is inserted C. confirm the correct position of the line by obtaining a blood sample D. place the head of the client's bed lower than the foot - C. confirm the correct position of the line by obtaining a blood sample A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? A. Monitor heart rate once daily. B. Take a laxative to prevent constipation. C. Drink 2 to 3 L of fluids daily. D. Take an antacid 30 min before taking the medication. - C. Drink 2 to 3 L of fluids daily. A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? A. "List some ways you can cope with the stress of your illness" B. "Name a few things you will change about your diet." C. "Tell me why it's important to have your CD4+ count checked" D. "Describe your daily medication schedule." - D. "Describe your daily medication schedule." A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea10 min after the infusion begins. Which of the following actions should the nurse take first ? A. Stop the infusion. B. Collect a urine sample. C. Check the client's vital signs. D. Administer oxygen to the client. - A. Stop the infusion. A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse? A. Reinforce the importance of lying still during the procedure. B. Determine whether the client has a allergy to local anesthetics. C. Administer a sedative medication. D. Describe the sensations the client will feel during the procedure. - B. Determine whether the client has a allergy to local anesthetics. A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? A. Use contact isolation while providing care. B. Move the client to a negative pressure room. C. Apply pressure to venipuncture pressure room. D. Instruct the client to avoid eating raw fruit. - D. Instruct the client to avoid eating raw fruit. A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A. Reports pain of 4 on a scale from 0 to 10 when coughing B. WBC count 8,400/mm3 C. Serosanguineous exudate noted on dressing change D. Hemoglobin 10 mg/ dL - D. Hemoglobin 10 mg/ dL A nurse is caring for a client who was admitted with nausea, vomiting, and possible bowel obstruction. An Ng tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? A. The amount of drainage is gradually decreasing. B. The drainage is bright green in color with brown fecal material. C. The client's abdomen becomes distended and firm. D. The client reports being extremely thirsty with a sore throat. - C. The client's abdomen becomes distended and firm. A nurse is reviewing the medical record of a client who is scheduled for a CT scan with a contrast media. Which of the following medications should the nurse instruct the client to withhold for 48hr following the procedure? A. Carvedilol B. Metformin C. Clopidogrel D. Furosemide - B. Metformin A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? A. Instill 0.9% sodium chloride solution into the affected eye. B. Administer proparacaine eye drops into the affected eye. C. Place a strip of PH paper onto the cul-de-sac of the affected eye. D. Collect information about the irritant that caused the injury. - A. Instill 0.9% sodium chloride solution into the affected eye. A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? A. "I use my heating pad on a low setting to keep my feet warm." B. "I apply a lubricating lotion to the cracked areas on the soles of my feet every morning." C. "I rest in my recliner with my feet elevated for about an hour every afternoon." D. "I soak my feet in hot water before trimming my toenails." - C. "I rest in my recliner with my feet elevated for about an hour every afternoon." A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis? A. "Do you have any household pets, such as a cat?" B. "Was anyone in your family recently exposed to a viral disease?" C. "Are your immunizations current?" D. "Have you a been out of the country in the past 30 days?" - A. "Do you have any household pets, such as a cat?" A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? A. Polyuria B. Confusion C. Blurred vison D. Diarrhea - B. Confusion A nurse is checking a client's ventilator settings. The nurse should understand that positive endexpiratory pressure has which of the following purposes? A. To deliver a set tidal volume B. To prevent alveolar collapse C. To control the rate of ventilations D. To provide positive airway pressure during inspiration - D. To provide positive airway pressure during inspiration A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Client report of pain at the incision site B. Loose tracheal secretions C. Hypoactive bowel sounds D. High-pitched sound on inspiration - D. High-pitched sound on inspiration A nurse on a medical unit is planning care for a group of clients. Which of the following clients should the nurse attend to first? A. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% B. A client who has left-sided paralysis and slurred speech from a prior stroke C. A client who has multiple sclerosis and reports ataxia and vertigo D. A client who has thrombocytopenia and reports a nosebleed. - D. A client who has thrombocytopenia and reports a nosebleed. A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider A. Vigorously strip the chest tube twice daily. B. Notify the provider when tiddling ceases. C. Administer morphine 2 mg IV bolus every 3hr PRN for pain. D. Assist the client out of bed three times daily - A. Vigorously strip the chest tube twice daily. A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the pan of care? A. Instruct the client to avoid lifting the right arm for 72hr B. Check blood pressure in the right arm C. Insert a saline lock into a site 10 cm (4 in) distal to the graft D. Palpate the site for a thrill - D. Palpate the site for a thrill A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral? A. The client has a prescription for a furosemide B. The client has a prescription for long term IV antibiotic therapy C. The client has a WBC count of 20,000/mm3. D. The client has type 2 diabetes mellites and HDA1C of 5 %. - B. The client has a prescription for long term IV antibiotic therapy A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first? A. Ensure the tubing connections are secure B. Reposition the client's left arm C. Flush the IV catheter D. Check the IV site for redness - A. Ensure the tubing connections are secure A nurse is caring for a client who is 6hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? A. Maintain the affected extremity in a dependent position B. Wrap sterile gauze on the sharp point of the pins C. Adjust the clamps on the fixator frame D. Palpate the dorsalis pedis pulse. - D. Palpate the dorsalis pedis pulse. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level on a pain scale of 0 to 10. Which of the following interventions should the nurse take? A. Place pillows under the client's knee B. Gently massage the area around the client's incision C. Apply an ice pack to the client's knee D. Perform range-of-motion exercises to the client's knee - A. Place pillows under the client's knee A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? A. Fever B. Cloudy effluent C. Increased heart rate D. Generalized abdominal pain - B. Cloudy effluent A nurse in a emergency department is caring for a client who is to receive tissue plasminogen activator (TPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them into the selected order of performance. Use all the steps.) a- Check for contraindications. b- Transfer the client to the CCU c- Weigh the client d- Administer the TPA - c, a, d, b A nurse is assessing a client who has acute pancreatitis and has been receiving a total parenteral nutrition for the past 72hr. Which of the following findings requires the nurse to intervene? A. Capillary blood glucose level 164 mg/dL B. Crackles in bilateral lower lobes C. WBC count 13,000/mm3 D. Right upper quadrant pain - B. Crackles in bilateral lower lobes A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity for which of the following clients? A. A client who has a right upper extremity arteriovenous fistula B. A client who has left-sided Bell's pal C. A client who has right-sided weakness due to Parkinson's disease D. A client who has a peripherally inserted central catheter (PICC) in the left arm - A. A client who has a right upper extremity arteriovenous fistula A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse? A. Administer 0.9% sodium chloride B. Initiate a continuous IV insulin infusion C. Check potassium levels. D. Begin bicarbonate continuous IV infusion - A. Administer 0.9% sodium chloride A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse. "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make? A. 'If you don't take this medication, you will feel worse." B. "Most clients feel better after taking the antibiotic." C. "Your provider wouldn't prescribe this medication if it weren't necessary'' D. "I will tell your provider that you do not want to take this medication" - C. "Your provider wouldn't prescribe this medication if it weren't necessary'' A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom D. Place a large-face clock in the client's bedroom - D. Place a large-face clock in the client's bedroom A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? A. A client who has peritonitis reports generalized abdominal pain. B. A client who is postoperative reports incisional pain. C. A client who has angina reports substernal chest pain. D. A client who has pancreatitis reports pain in the left shoulder. - D. A client who has pancreatitis reports pain in the left shoulder.