ATI RN MEDICAL SURGICAL WITH NGN
2024-2025 COMPLETE 180 QUESTIONS
AND CORRECT DETAILED ANSWERS
WITH RATIONALES
A nurse is caring for a client who has a leg cast and is returning to demonstrate
on the proper use of crutches while climbing stairs. Identify the sequence the
client should follow when demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair - Correct Answer - - Places body
weight on the crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
A nurse is caring for a client who has hypothyroidism. Which of the following
manifestations should the nurse expect?
- Constipation
- Insomnia
- Tachycardia
- Diaphoresis - Correct Answer - - Constipation
RATIONALE: A client who has hypothyroidism can experience constipation due
to the decrease in the client's metabolism, resulting in slow motility of the GI
tract. The nurse should instruct the client to increase fiber and fluid intake to
reduce the risk for constipation.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which
of the following nonpharmacological interventions should the nurse suggest to
the client to reduce pain?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints - Correct Answer - - Alternate application
of heat and cold to the affected joints
RATIONALE: The nurse should instruct the client to alternate heat and cold
applications to decrease joint inflammation and pain. The application of cold can
relieve joint swelling and the application of heat can decrease joint stiffness and
pain.
A nurse is caring for a client who is receiving a blood transfusion. The client
becomes restless, dyspneic, and has crackles noted to the lung bases. Which of
the following actions should the nurse anticipate taking?
- Administer an antihistamine
,- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities - Correct Answer - - Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood
transfusion are manifestations of circulatory overload. The nurse should slow or
stop the infusion to improve the client's ability to breath, place the client in an
upright position, and notify the provider. The provider might prescribe a diuretic
to alleviate the fluid overload.
A nurse in the emergency department is assessing a client who has a detached
retina. Which of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks."
- "I seem to have more problems seeing different colors." - Correct Answer - -
"It's like a curtain closed over my eye."
RATIONALE: A retinal detachment is the separation of the retina from the
epithelium. It can occur because of trauma, cataract surgery, retinopathy, or
uveitis. Clients who have retinal detachment typically report the sensation of a
curtain being pulled over part of the visual field.
A nurse is teaching a client who has a family history of colorectal cancer. To help
mitigate this risk, which of the following dietary alterations should the nurse
recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat - Correct Answer - - Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should
consume a diet that is high in fiber, low in fat, and low in refined carbohydrates.
Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions
should the nurse take? (Select all that apply.)
- Ask the client to rate their pain on a 0 to 10 pain scale
- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Apply oxygen via a face mask
- Report urinary output to the provider - Correct Answer - - Instruct the client to
splint the abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and deep breathe to
reduce the risk for respiratory complications. The nurse should instruct the client
to splint the incision while performing these actions to reduce the risk of
complications to the surgical incision.
- Plan to ambulate the client as soon as possible
RATIONALE: The nurse should plan to ambulate the client as soon as possible to
promote ventilation and decrease the risk of thrombosis..
, - Report urinary output to the provider
RATIONALE: The client should produce at least 30 mL of urine per hour.
Therefore, the nurse should report this finding to the provider.
- Ask the client to rate their pain on a 0 to 10 pain scale
RATIONALE: The nurse should have the client rate their pain prior to and
following the administration of pain medication to evaluate its effectiveness.
A nurse is caring for a client who is postoperative following a total hip
arthroplasty. Which of the following findings indicates that the client is
experiencing a complication?
- The client reports that the sequential compression devices (SCDs) are
uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to
drainage
- The client needs assistance with a walker when ambulating in the room - Correct
Answer - - The client's surgical site dressing has required changing twice in 2 hr
due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor
clotting and increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood
mixed with food after a meal. Which of the following actions should the nurse
take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs - Correct Answer - - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is
to assess the client's vital signs. A client who has portal HTN can develop
esophageal varices, which are fragile and can rupture, resulting in large amounts
of blood loss and shock. Obtaining vital signs provides information about the
client's condition that can contribute to decision making.
A nurse is providing teaching to a female client who has stress incontinence and
a BMI of 32. Which of the following statements by the client indicates an
understanding of the teaching?
- "Taking my daily progesterone should improve my symptoms."
- "A risk factor for my condition is obesity."
- "I should limit my daily fluid intake."
- "I will switch my morning cup of coffee to hot tea." - Correct Answer - - "A risk
factor for my condition is obesity."
RATIONALE: Excess weight creates increased abdominal pressure that can result
in stress incontinence.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
- "Ginkgo biloba relieves nausea for people who have vertigo."
- "Taking ginkgo biloba will help relieve your joint pain."
- "Ginkgo biloba can cause an increased risk for bleeding."
2024-2025 COMPLETE 180 QUESTIONS
AND CORRECT DETAILED ANSWERS
WITH RATIONALES
A nurse is caring for a client who has a leg cast and is returning to demonstrate
on the proper use of crutches while climbing stairs. Identify the sequence the
client should follow when demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair - Correct Answer - - Places body
weight on the crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
A nurse is caring for a client who has hypothyroidism. Which of the following
manifestations should the nurse expect?
- Constipation
- Insomnia
- Tachycardia
- Diaphoresis - Correct Answer - - Constipation
RATIONALE: A client who has hypothyroidism can experience constipation due
to the decrease in the client's metabolism, resulting in slow motility of the GI
tract. The nurse should instruct the client to increase fiber and fluid intake to
reduce the risk for constipation.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which
of the following nonpharmacological interventions should the nurse suggest to
the client to reduce pain?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints - Correct Answer - - Alternate application
of heat and cold to the affected joints
RATIONALE: The nurse should instruct the client to alternate heat and cold
applications to decrease joint inflammation and pain. The application of cold can
relieve joint swelling and the application of heat can decrease joint stiffness and
pain.
A nurse is caring for a client who is receiving a blood transfusion. The client
becomes restless, dyspneic, and has crackles noted to the lung bases. Which of
the following actions should the nurse anticipate taking?
- Administer an antihistamine
,- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities - Correct Answer - - Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood
transfusion are manifestations of circulatory overload. The nurse should slow or
stop the infusion to improve the client's ability to breath, place the client in an
upright position, and notify the provider. The provider might prescribe a diuretic
to alleviate the fluid overload.
A nurse in the emergency department is assessing a client who has a detached
retina. Which of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks."
- "I seem to have more problems seeing different colors." - Correct Answer - -
"It's like a curtain closed over my eye."
RATIONALE: A retinal detachment is the separation of the retina from the
epithelium. It can occur because of trauma, cataract surgery, retinopathy, or
uveitis. Clients who have retinal detachment typically report the sensation of a
curtain being pulled over part of the visual field.
A nurse is teaching a client who has a family history of colorectal cancer. To help
mitigate this risk, which of the following dietary alterations should the nurse
recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat - Correct Answer - - Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should
consume a diet that is high in fiber, low in fat, and low in refined carbohydrates.
Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is caring for a client who is postoperative following abdominal surgery.
A nurse is caring for a client who is postoperative. Which of the following actions
should the nurse take? (Select all that apply.)
- Ask the client to rate their pain on a 0 to 10 pain scale
- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Apply oxygen via a face mask
- Report urinary output to the provider - Correct Answer - - Instruct the client to
splint the abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and deep breathe to
reduce the risk for respiratory complications. The nurse should instruct the client
to splint the incision while performing these actions to reduce the risk of
complications to the surgical incision.
- Plan to ambulate the client as soon as possible
RATIONALE: The nurse should plan to ambulate the client as soon as possible to
promote ventilation and decrease the risk of thrombosis..
, - Report urinary output to the provider
RATIONALE: The client should produce at least 30 mL of urine per hour.
Therefore, the nurse should report this finding to the provider.
- Ask the client to rate their pain on a 0 to 10 pain scale
RATIONALE: The nurse should have the client rate their pain prior to and
following the administration of pain medication to evaluate its effectiveness.
A nurse is caring for a client who is postoperative following a total hip
arthroplasty. Which of the following findings indicates that the client is
experiencing a complication?
- The client reports that the sequential compression devices (SCDs) are
uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to
drainage
- The client needs assistance with a walker when ambulating in the room - Correct
Answer - - The client's surgical site dressing has required changing twice in 2 hr
due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor
clotting and increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood
mixed with food after a meal. Which of the following actions should the nurse
take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs - Correct Answer - - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is
to assess the client's vital signs. A client who has portal HTN can develop
esophageal varices, which are fragile and can rupture, resulting in large amounts
of blood loss and shock. Obtaining vital signs provides information about the
client's condition that can contribute to decision making.
A nurse is providing teaching to a female client who has stress incontinence and
a BMI of 32. Which of the following statements by the client indicates an
understanding of the teaching?
- "Taking my daily progesterone should improve my symptoms."
- "A risk factor for my condition is obesity."
- "I should limit my daily fluid intake."
- "I will switch my morning cup of coffee to hot tea." - Correct Answer - - "A risk
factor for my condition is obesity."
RATIONALE: Excess weight creates increased abdominal pressure that can result
in stress incontinence.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
- "Ginkgo biloba relieves nausea for people who have vertigo."
- "Taking ginkgo biloba will help relieve your joint pain."
- "Ginkgo biloba can cause an increased risk for bleeding."
