ATI EXIT EXAM MED SURG II \\PN
ATI COMPREHENSIVE EXAM WITH
NGN 2024 ALREADY GRADED A+
Rationale: The client's score is calculated correctly, indicating moderate
head injury. E3 represents opening eyes secondary to voice stimulation, V4
represents the verbal conversation that is incoherent and disoriented and M4
represents motor response as general withdrawal to pain.
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the
client should the nurse report to the provider? (Select all that apply).
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning." - ANS✔✔--A. "I think I might be
pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
,Rationale: (A) The nurse should report the client's statement of possible
pregnancy to the provider because the contrast dye can place the fetus at
risk. (B) The nurse should report that the client is taking warfarin to the
provider due to the potential for bleeding following angiography (D) The nurse
should report a clients report of allergy to shrimp, which is a shellfish, to the
provider due to a potential allergic reaction to the contrast dye (E) The nurse
should report a client's intake of food to the provider since the client should
remain NPO for 4 to 6 hr. prior to the procedure.
A nurse is caring for a client who is postprocedure following a lumbar
puncture and reports a throbbing headache when sitting upright. Which of
the following actions should the nurse take? (Select all that apply).
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises. -
ANS✔✔--B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which
can relieve a headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of
headache pain. (D) The nurse should encourage increased fluid intake to
maintain a positive fluid balance, which can relieve a headache following a
lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and
has an intraventricular catheter (ventriculostomy) for ICP monitoring. The
,nurse should monitor the client for which of the following complications
related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - ANS✔✔--B. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy for
infection, which is a complication. The nurse should use strict asepsis to
avoid this life-threatening condition, which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using
the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to,
speaks incoherently, and moves his extremities when pain is applied. Which
of the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ANS✔✔--B. E3 + V4 + M4 = 11
A nurse is providing education to a client who is to undergo an
electroencephalogram (EEG) the next day. Which of the following information
should the nurse include in the teaching?
A. "Do not wash your hair the morning of the procedure."
B. "Try to stay away most of the night prior to the procedure."
C. "The procedure will take approximately 15 minutes."
, D. "You will need to lie flat for 4 hours after the procedure." - ANS✔✔--B.
"Try to stay away most of the night prior to the procedure."
Rationale: The nurse should teach the client to remain awake most of the
night to provide cranial stress and increase the possibility of abnormal
electrical activity.
A nurse is assessing the pain level of a client who came to the emergency
department reporting severe abdominal pain. The nurse asks the client
whether he has nausea and has been vomiting. The nurse is assessing which
of the following components of a pain assessment?
A. Presence of associated manifestations.
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors - ANS✔✔--A. Presence of associated
manifestations.
Rationale: Nausea and vomiting are common manifestations clients have
when they are in pain
A nurse is assessing a client who is reporting pain despite analgesia. Which
of the following actions should the nurse take to assess the intensity of the
client's pain?
A. Ask the client what precipitates his pain.
B. Question the client about the location of his pain.
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the sensation of his pain. - ANS✔✔-
-C. Offer the client a pain scale to measure his pain
ATI COMPREHENSIVE EXAM WITH
NGN 2024 ALREADY GRADED A+
Rationale: The client's score is calculated correctly, indicating moderate
head injury. E3 represents opening eyes secondary to voice stimulation, V4
represents the verbal conversation that is incoherent and disoriented and M4
represents motor response as general withdrawal to pain.
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the
client should the nurse report to the provider? (Select all that apply).
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning." - ANS✔✔--A. "I think I might be
pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
,Rationale: (A) The nurse should report the client's statement of possible
pregnancy to the provider because the contrast dye can place the fetus at
risk. (B) The nurse should report that the client is taking warfarin to the
provider due to the potential for bleeding following angiography (D) The nurse
should report a clients report of allergy to shrimp, which is a shellfish, to the
provider due to a potential allergic reaction to the contrast dye (E) The nurse
should report a client's intake of food to the provider since the client should
remain NPO for 4 to 6 hr. prior to the procedure.
A nurse is caring for a client who is postprocedure following a lumbar
puncture and reports a throbbing headache when sitting upright. Which of
the following actions should the nurse take? (Select all that apply).
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises. -
ANS✔✔--B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which
can relieve a headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of
headache pain. (D) The nurse should encourage increased fluid intake to
maintain a positive fluid balance, which can relieve a headache following a
lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and
has an intraventricular catheter (ventriculostomy) for ICP monitoring. The
,nurse should monitor the client for which of the following complications
related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - ANS✔✔--B. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy for
infection, which is a complication. The nurse should use strict asepsis to
avoid this life-threatening condition, which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using
the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to,
speaks incoherently, and moves his extremities when pain is applied. Which
of the following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ANS✔✔--B. E3 + V4 + M4 = 11
A nurse is providing education to a client who is to undergo an
electroencephalogram (EEG) the next day. Which of the following information
should the nurse include in the teaching?
A. "Do not wash your hair the morning of the procedure."
B. "Try to stay away most of the night prior to the procedure."
C. "The procedure will take approximately 15 minutes."
, D. "You will need to lie flat for 4 hours after the procedure." - ANS✔✔--B.
"Try to stay away most of the night prior to the procedure."
Rationale: The nurse should teach the client to remain awake most of the
night to provide cranial stress and increase the possibility of abnormal
electrical activity.
A nurse is assessing the pain level of a client who came to the emergency
department reporting severe abdominal pain. The nurse asks the client
whether he has nausea and has been vomiting. The nurse is assessing which
of the following components of a pain assessment?
A. Presence of associated manifestations.
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors - ANS✔✔--A. Presence of associated
manifestations.
Rationale: Nausea and vomiting are common manifestations clients have
when they are in pain
A nurse is assessing a client who is reporting pain despite analgesia. Which
of the following actions should the nurse take to assess the intensity of the
client's pain?
A. Ask the client what precipitates his pain.
B. Question the client about the location of his pain.
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the sensation of his pain. - ANS✔✔-
-C. Offer the client a pain scale to measure his pain
