ATI Proctored Med Surg
A hospice nurse is planning end-of-life comfort care for a client. Which of the following interventions should the nurse
include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
D. Remove visitors from the room if the Client becomes restless - ANS -C
Position laterally to improve breathing and promote comfort
\A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent
airway, which of the following nursing interventions is the priority?
A. Applying oxygen via face mask
B. Placing the client in Fowler's position
C. Administering epinephrine
D. Initiating an IV infusion of 0.9% sodium chloride - ANS -A
Fowler's position to promote lung expansion after the nurse determines that the client is not hypotensive. Epinephrine
quickly to prevent circulatory shock, but oxygen first. IV NS to maintain IV access and prevent circulatory collapse after
oxygen administration.
\A nurse in the emergency department is assessing a client who was admitted following a traumatic brain injury (TBI).
Which of the following findings should the nurse identify as an indication of increased ICP?
A. Ecchymosis around both eyes
B. Asymmetric pupils
C. Hypotension
D. Leaking cerebral spinal fluid (CSF) from nose or ears - ANS -B
Ecchymosis and leaking CSF can indicate basilar skull fracture. HTN associated with increased ICP.
\A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic
transfusion reaction?
,A. Anorexia and jaundice
B. Bronchospasm and urticaria
C. Hypertension and bounding pulse
D. Low back pain and apprehension - ANS -D
Causes a systemic inflammatory response with manifestations of low back pain, hypotension, tachycardia, and
apprehension. Transfusion association graft versus host disease (within 14 days): thrombocytopenia, anorexia, nausea,
chronic hepatitis, weight loss. Allergic transfusion reactions (up to 24 hr): bronchospasm, urticaria (skin rash),
anaphylaxis. Circulatory overload (faster rate than client can tolerate): hypertension, restlessness, bounding pulses.
\A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just
undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of
advanced cancer?
A. Dyspnea
B. Hemoptysis
C. Mucus production
D. Dysphagia - ANS -A
Thoracentesis is the removal of pleural fluid and can temporarily relieve hypoxia and thus ease the client's breathing and
improve comfort. Hemoptysis is coughing up blood and is common with advanced lung cancer. Thick muscus and sputum
are likely in a client with advanced lung cancer. Dysphagia caused by advanced lung cancer results from esophageal
compression and is not likely to improve after thoracentesis.
\A nurse is assessing a client who has an endotracheal tube and is receiving mechanical ventilation. The client is agitated
and appears to be in respiratory distress. Which of the following actions should the nurse take first?
A. Manually ventilate the client using a bag-valve device
B. Suction the client's endotracheal tube
C. Contact the respiratory therapist to check the client's ventilator
D. Obtain ABGs from the client - ANS -A
Using ABC, the nurse should provide manual ventilation to reduce the risk for injury due to hypoxia. Should disconnect the
ventilator in case it is not functioning properly and provide oxygenation until further assessment is obtained
\A nurse is assessing a client who has diabetes insidious. Which of the following findings should the nurse expect?
A. Low urine specific gravity
, B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia - ANS -A
Expected finding is a urine specific gravity between 1.001-1.005 because of decreased water reabsorption by the renal
tubules caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
Hypotension, weak peripheral pulses, polydipsia, and polyuria are expected with DI. Hyperglycemia is expected with DM.
\A nurse is assessing a client who has dry age-related macular degeneration (AMD) of the left eye. Which of the following
findings should the nurse expect?
A. Purulent dischange
B. Pain with blinking
C. Gradual decrease of central vision
D. Petechiae on the surrounding skin - ANS -C
Manifestation of dry AMD. As it progresses, the client will experience a total loss of the central visual field.
\A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's
priority?
A. Moderate serosanguinous drainage on the dressing
B. Calcium 9.5 mg/dL
C. Temperature 38.9ºC (102ºF)
D. Decreased bowel sounds - ANS -C
Elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
metabolic rate. It can lead to seizures and coma. Moderate serosanguinous drainage is expected. Calcium of 9.5mg/dL is
within normal range, but should monitor for hypocalcemia following a thyroidectomy. Decreased bowel sounds is expected
in a client who is postoperative due to anesthesia.
\A nurse is assessing a client who is receiving head and neck radiation therapy to treat esophageal cancer. The nurse
should identify which of the following findings as an adverse effect of this treatment?
A. The client has a productive cough
B. The client reports peripheral neuropathy
C. The client reports a dry mouth
D. The client reports diarrhea - ANS -C
A hospice nurse is planning end-of-life comfort care for a client. Which of the following interventions should the nurse
include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
D. Remove visitors from the room if the Client becomes restless - ANS -C
Position laterally to improve breathing and promote comfort
\A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent
airway, which of the following nursing interventions is the priority?
A. Applying oxygen via face mask
B. Placing the client in Fowler's position
C. Administering epinephrine
D. Initiating an IV infusion of 0.9% sodium chloride - ANS -A
Fowler's position to promote lung expansion after the nurse determines that the client is not hypotensive. Epinephrine
quickly to prevent circulatory shock, but oxygen first. IV NS to maintain IV access and prevent circulatory collapse after
oxygen administration.
\A nurse in the emergency department is assessing a client who was admitted following a traumatic brain injury (TBI).
Which of the following findings should the nurse identify as an indication of increased ICP?
A. Ecchymosis around both eyes
B. Asymmetric pupils
C. Hypotension
D. Leaking cerebral spinal fluid (CSF) from nose or ears - ANS -B
Ecchymosis and leaking CSF can indicate basilar skull fracture. HTN associated with increased ICP.
\A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic
transfusion reaction?
,A. Anorexia and jaundice
B. Bronchospasm and urticaria
C. Hypertension and bounding pulse
D. Low back pain and apprehension - ANS -D
Causes a systemic inflammatory response with manifestations of low back pain, hypotension, tachycardia, and
apprehension. Transfusion association graft versus host disease (within 14 days): thrombocytopenia, anorexia, nausea,
chronic hepatitis, weight loss. Allergic transfusion reactions (up to 24 hr): bronchospasm, urticaria (skin rash),
anaphylaxis. Circulatory overload (faster rate than client can tolerate): hypertension, restlessness, bounding pulses.
\A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just
undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of
advanced cancer?
A. Dyspnea
B. Hemoptysis
C. Mucus production
D. Dysphagia - ANS -A
Thoracentesis is the removal of pleural fluid and can temporarily relieve hypoxia and thus ease the client's breathing and
improve comfort. Hemoptysis is coughing up blood and is common with advanced lung cancer. Thick muscus and sputum
are likely in a client with advanced lung cancer. Dysphagia caused by advanced lung cancer results from esophageal
compression and is not likely to improve after thoracentesis.
\A nurse is assessing a client who has an endotracheal tube and is receiving mechanical ventilation. The client is agitated
and appears to be in respiratory distress. Which of the following actions should the nurse take first?
A. Manually ventilate the client using a bag-valve device
B. Suction the client's endotracheal tube
C. Contact the respiratory therapist to check the client's ventilator
D. Obtain ABGs from the client - ANS -A
Using ABC, the nurse should provide manual ventilation to reduce the risk for injury due to hypoxia. Should disconnect the
ventilator in case it is not functioning properly and provide oxygenation until further assessment is obtained
\A nurse is assessing a client who has diabetes insidious. Which of the following findings should the nurse expect?
A. Low urine specific gravity
, B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia - ANS -A
Expected finding is a urine specific gravity between 1.001-1.005 because of decreased water reabsorption by the renal
tubules caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
Hypotension, weak peripheral pulses, polydipsia, and polyuria are expected with DI. Hyperglycemia is expected with DM.
\A nurse is assessing a client who has dry age-related macular degeneration (AMD) of the left eye. Which of the following
findings should the nurse expect?
A. Purulent dischange
B. Pain with blinking
C. Gradual decrease of central vision
D. Petechiae on the surrounding skin - ANS -C
Manifestation of dry AMD. As it progresses, the client will experience a total loss of the central visual field.
\A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's
priority?
A. Moderate serosanguinous drainage on the dressing
B. Calcium 9.5 mg/dL
C. Temperature 38.9ºC (102ºF)
D. Decreased bowel sounds - ANS -C
Elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
metabolic rate. It can lead to seizures and coma. Moderate serosanguinous drainage is expected. Calcium of 9.5mg/dL is
within normal range, but should monitor for hypocalcemia following a thyroidectomy. Decreased bowel sounds is expected
in a client who is postoperative due to anesthesia.
\A nurse is assessing a client who is receiving head and neck radiation therapy to treat esophageal cancer. The nurse
should identify which of the following findings as an adverse effect of this treatment?
A. The client has a productive cough
B. The client reports peripheral neuropathy
C. The client reports a dry mouth
D. The client reports diarrhea - ANS -C
