ATI PN Med Surg Exam| 180 Questions
Complete with Correct Answers and
Verified Explanations
A nurse is caring for a client who has restricted movement of the chest due to a burn
injury. The nurse should anticipate preparing the client for which of the following
procedures? CORRECT ANSWER: Escharotomy
Rationale:
The nurse should anticipate a prescription for an escharotomy to relieve constriction of
the client's chest due to a burn injury. Following removal of the eschar, chest wall
movement will be possible, and the client's oxygenation should improve.
A fasciotomy is used to treat compartment syndrome for clients following traumatic
musculoskeletal injury.
Skin grafting is used to promote wound healing for clients who have large wounds, like
burn injuries.
Hyperbaric oxygen therapy involves high pressure oxygen therapy and is part of
treatment for life-threatening wound infections.
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the
following actions should the nurse take to reduce the client's confusion? CORRECT
ANSWER: Encourage reminiscence of past experiences.
Rationale:
The nurse should encourage reminiscence of past experiences to reduce the client's
confusion.
A nurse is reinforcing teaching about hospice care with a client who has terminal cancer.
Which of the following statements should the nurse make? CORRECT ANSWER:
"Hospice care will provide support for you and your loved ones during the dying
process."
Rationale:
The nurse should inform the client that hospice care supports clients and their loved
ones with the goal of helping provide a peaceful and dignified death.
The nurse should inform the client that a DNR order is required to receive hospice
services.
The nurse should inform the client that hospice care can be provided in a variety of
settings.
,The nurse should inform the client that nursing care is available 24 hr a day for all 7
days of the week as part of hospice services.
A nurse in a telemetry unit is collecting date from a client who has a newly-inserted
permanent pacemaker. Which of the following findings should the nurse report to the
provider? CORRECT ANSWER: The client experiences hiccups when sitting.
Rationale:
The nurse should monitor clients who have a newly-inserted permanent pacemaker for
hiccups because this finding can indicate that the pacemaker wires are displaced or that
the pacemaker is not firing properly. Therefore, the nurse should report this finding to
the provider.
A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for
a client who has a peptic ulcer disease and has developed gastrointestinal bleeding.
Which of the following images depicts the tube that the nurse should select?
CORRECT ANSWER: Option A
Rationale:
When using a double-lumen gastric sump tube, the clear portion of the tube allows for
aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the
tube to the atmosphere, which prevents the tube from becoming lodged against the wall
of the stomach and protects the stomach from damage.
A nurse is caring for a clietn who has Cushing's syndrome and expresses concern
regarding physical changes associated with the syndrome. Which of the follwoing should
the nurse recognize as a physical change caused by this disorder? CORRECT
ANSWER: Truncal obesity
Rationale:
Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a
redistribution of fat. The client also usually has fatty tissue edema between the scapula,
also known as "buffalo hump". The nurse should use therapeutic communication
techniques to investigate the client's body image concerns.
-------------
The nurse should expect a client who has Addison's disease to experience bronzing of
the skin of the knuckles, knees, and elbows. Ecchymosis and thinning of the skin are
expected findings of Cushing's syndrome.
The nurse should recognize that lordosis is an increase in the curvature of the lumbar
spine, which is common for clients who have poor posture. Muscle wasting and thinning
of the extremities are expected findings of Cushing's syndrome.
,The nurse should expect a client who has Grave's disease to experience exophthalmos.
Facial edema, also known as "moon face", and flushing of the cheeks are expected
findings of Cushing's syndrome.
A nurse is caring for a client who begines to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps in order)
CORRECT ANSWER: Lower the client to floor is the first step. The nurse should
lower the client to the floor to prevent the client from falling.Place a pad beneath the
client's head is the second step. The nurse should place a pad beneath the client's head
to protect the client from injury.Loosen the clothing around the client's neck is the third
step. The nurse should loosen clothing around the client's neck to allow for easier
ventilation.Time the length of the client's seizure is the fourth step. The nurse should
note the time the seizure began for accurate reporting.Reorient and reassure the client is
the fifth step. The nurse should reorient and reassure the client because confusion and
embarrassment are common following a seizure.
CORRECT ANSWER: I can develop TB by breathing in the infection."
Rationale:
TB is spread by airborne transmission. Therefore, the nurse should identify this
statement as an understanding of the teaching.
---
The nurse should reinforce that a person exposed to TB can develop the infection within
3 to 10 weeks following the exposure.
The nurse should reinforce that a positive reaction to the tuberculin skin test indicates
an immune response, not that the client is actively infected.
The nurse should reinforce that persons who live with or have close contact with the
client are already exposed to the disease. Therefore, wearing a mask in the house is not
necessary.
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which
of the following interventions should the nurse include? CORRECT ANSWER: Place
the client in a negative-pressure airflow room.
Rationale:
The nurse should place the client in a negative-pressure airflow room to filter the air and
prevent the transmission of micro-organisms.
----
The nurse should implement droplet precautions for a client who has rubella or
pertussis.
, The nurse should place a surgical mask on the client when transporting them outside of
the room to prevent the transmission of micro-organisms.
Clients who have TB can have visitors. However, visitors should follow transmission
precautions.
A nurse is reviewing the medical record for a client who is experiencing nausea and
vomiting. Bases on the client data, which of the following actions should the nurse take?
(Click on exhibit tabs)
Exhibit 1 tab: Diagnositic Results:
Sodium 142 mEq/L
Potassium 4.2 mEq/L
BUN 36 mg/dL
Creatinine 1.4 mg/dL
Exhibit 2 tab: Nurses' Notes:
1200: Alert and oriented x3
Lungs clear to auscultation
Decreased skin turgor
Dry mucous membranes
Exhibit 3 tab: Graphic Record
Temperature
0800: 37.7° C (99.9° F)
1200: 37.2° C (99° F)
Pulse
0800: 96/min
1200: 105/min
Respiratory rate
0800: 18/min
1200: 20/min
Blood pressure
0800: 118/62 mm Hg
1200: 104/65 mm Hg CORRECT ANSWER: Notify the charge nurse of the client's
BUN level.
Rationale:
The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which
can indicate impaired renal function. The nurse should anticipate interventions to
restore the client's fluid volume.
A nurse is reinforcing teaching with a client who has a diagnosis of tuberculosis (TB)
and a prescription for isoniazid and rifampin. Which of the following information
should the nurse include in the teaching? CORRECT ANSWER: Household family
members should be tested for TB.
Rationale:
Complete with Correct Answers and
Verified Explanations
A nurse is caring for a client who has restricted movement of the chest due to a burn
injury. The nurse should anticipate preparing the client for which of the following
procedures? CORRECT ANSWER: Escharotomy
Rationale:
The nurse should anticipate a prescription for an escharotomy to relieve constriction of
the client's chest due to a burn injury. Following removal of the eschar, chest wall
movement will be possible, and the client's oxygenation should improve.
A fasciotomy is used to treat compartment syndrome for clients following traumatic
musculoskeletal injury.
Skin grafting is used to promote wound healing for clients who have large wounds, like
burn injuries.
Hyperbaric oxygen therapy involves high pressure oxygen therapy and is part of
treatment for life-threatening wound infections.
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the
following actions should the nurse take to reduce the client's confusion? CORRECT
ANSWER: Encourage reminiscence of past experiences.
Rationale:
The nurse should encourage reminiscence of past experiences to reduce the client's
confusion.
A nurse is reinforcing teaching about hospice care with a client who has terminal cancer.
Which of the following statements should the nurse make? CORRECT ANSWER:
"Hospice care will provide support for you and your loved ones during the dying
process."
Rationale:
The nurse should inform the client that hospice care supports clients and their loved
ones with the goal of helping provide a peaceful and dignified death.
The nurse should inform the client that a DNR order is required to receive hospice
services.
The nurse should inform the client that hospice care can be provided in a variety of
settings.
,The nurse should inform the client that nursing care is available 24 hr a day for all 7
days of the week as part of hospice services.
A nurse in a telemetry unit is collecting date from a client who has a newly-inserted
permanent pacemaker. Which of the following findings should the nurse report to the
provider? CORRECT ANSWER: The client experiences hiccups when sitting.
Rationale:
The nurse should monitor clients who have a newly-inserted permanent pacemaker for
hiccups because this finding can indicate that the pacemaker wires are displaced or that
the pacemaker is not firing properly. Therefore, the nurse should report this finding to
the provider.
A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for
a client who has a peptic ulcer disease and has developed gastrointestinal bleeding.
Which of the following images depicts the tube that the nurse should select?
CORRECT ANSWER: Option A
Rationale:
When using a double-lumen gastric sump tube, the clear portion of the tube allows for
aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the
tube to the atmosphere, which prevents the tube from becoming lodged against the wall
of the stomach and protects the stomach from damage.
A nurse is caring for a clietn who has Cushing's syndrome and expresses concern
regarding physical changes associated with the syndrome. Which of the follwoing should
the nurse recognize as a physical change caused by this disorder? CORRECT
ANSWER: Truncal obesity
Rationale:
Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a
redistribution of fat. The client also usually has fatty tissue edema between the scapula,
also known as "buffalo hump". The nurse should use therapeutic communication
techniques to investigate the client's body image concerns.
-------------
The nurse should expect a client who has Addison's disease to experience bronzing of
the skin of the knuckles, knees, and elbows. Ecchymosis and thinning of the skin are
expected findings of Cushing's syndrome.
The nurse should recognize that lordosis is an increase in the curvature of the lumbar
spine, which is common for clients who have poor posture. Muscle wasting and thinning
of the extremities are expected findings of Cushing's syndrome.
,The nurse should expect a client who has Grave's disease to experience exophthalmos.
Facial edema, also known as "moon face", and flushing of the cheeks are expected
findings of Cushing's syndrome.
A nurse is caring for a client who begines to have a seizure while ambulating in the hall.
Identify the sequence of actions the nurse should follow. (Move the steps in order)
CORRECT ANSWER: Lower the client to floor is the first step. The nurse should
lower the client to the floor to prevent the client from falling.Place a pad beneath the
client's head is the second step. The nurse should place a pad beneath the client's head
to protect the client from injury.Loosen the clothing around the client's neck is the third
step. The nurse should loosen clothing around the client's neck to allow for easier
ventilation.Time the length of the client's seizure is the fourth step. The nurse should
note the time the seizure began for accurate reporting.Reorient and reassure the client is
the fifth step. The nurse should reorient and reassure the client because confusion and
embarrassment are common following a seizure.
CORRECT ANSWER: I can develop TB by breathing in the infection."
Rationale:
TB is spread by airborne transmission. Therefore, the nurse should identify this
statement as an understanding of the teaching.
---
The nurse should reinforce that a person exposed to TB can develop the infection within
3 to 10 weeks following the exposure.
The nurse should reinforce that a positive reaction to the tuberculin skin test indicates
an immune response, not that the client is actively infected.
The nurse should reinforce that persons who live with or have close contact with the
client are already exposed to the disease. Therefore, wearing a mask in the house is not
necessary.
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which
of the following interventions should the nurse include? CORRECT ANSWER: Place
the client in a negative-pressure airflow room.
Rationale:
The nurse should place the client in a negative-pressure airflow room to filter the air and
prevent the transmission of micro-organisms.
----
The nurse should implement droplet precautions for a client who has rubella or
pertussis.
, The nurse should place a surgical mask on the client when transporting them outside of
the room to prevent the transmission of micro-organisms.
Clients who have TB can have visitors. However, visitors should follow transmission
precautions.
A nurse is reviewing the medical record for a client who is experiencing nausea and
vomiting. Bases on the client data, which of the following actions should the nurse take?
(Click on exhibit tabs)
Exhibit 1 tab: Diagnositic Results:
Sodium 142 mEq/L
Potassium 4.2 mEq/L
BUN 36 mg/dL
Creatinine 1.4 mg/dL
Exhibit 2 tab: Nurses' Notes:
1200: Alert and oriented x3
Lungs clear to auscultation
Decreased skin turgor
Dry mucous membranes
Exhibit 3 tab: Graphic Record
Temperature
0800: 37.7° C (99.9° F)
1200: 37.2° C (99° F)
Pulse
0800: 96/min
1200: 105/min
Respiratory rate
0800: 18/min
1200: 20/min
Blood pressure
0800: 118/62 mm Hg
1200: 104/65 mm Hg CORRECT ANSWER: Notify the charge nurse of the client's
BUN level.
Rationale:
The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which
can indicate impaired renal function. The nurse should anticipate interventions to
restore the client's fluid volume.
A nurse is reinforcing teaching with a client who has a diagnosis of tuberculosis (TB)
and a prescription for isoniazid and rifampin. Which of the following information
should the nurse include in the teaching? CORRECT ANSWER: Household family
members should be tested for TB.
Rationale:
