ATI RN ADULT MEDICAL SURGICAL EXAM
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? - ANS Flex
the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the
risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage
system. Which of the following findings is an indication of lung re-expansion? - ANS
Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic
atrial fibrillation. Which of the following values should the nurse identify as a desired
outcome for this therapy? - ANS INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial
infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an
anticoagulant, the medication must be monitored to ensure the anticoagulation is within
the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke,
MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic
range of 2 to 3 for a client who has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury
on the greater trochanter of his left hip. Which of the following instructions should the
nurse include in the teaching? - ANS Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences.
The nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30°. This positioning prevents direct pressure on the
trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider? - ANS Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is restlessness, which can be
an indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and can
,lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting,
fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty.
The client is unable to void on the bedpan. Which of the following actions should the
nurse take first? - ANS Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is to assess
the client. Scanning the bladder with a portable ultrasound device will determine the
amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African American
clients at a community center. Which of the following disorders presents the greatest
risk to this group of clients? - ANS Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving? - ANS Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's
status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago.
Which of the following findings should the nurse report to the provider immediately? -
ANS Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is stridor. Stridor can indicate a narrowing airway or
possible obstruction caused by edema or laryngeal spasms. The nurse should report
the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of
the following findings should the nurse report to the provider? - ANS The client reports
back pain
Rationale: The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANS Airborne
, Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such as
tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical
cancer. Which of the following interventions should the nurse include in the plan of
care? - ANS Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room
in case of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of
the following findings is the nurse's priority? - ANS Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is an elevated temperature. An elevated
temperature is a manifestation of excessive thyroid hormone release, or thyroid storm,
due to an increase in metabolic rate. The nurse should report this finding immediately to
the provider because it can lead to seizures and coma.
A nurse is providing discharge teaching about infection prevention to a client who has
AIDS. Which of the following statements by the client indicates understanding of the
teaching? - ANS "I will no longer floss my teeth after brushing my teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
A nurse is providing teaching to a client who has hypertension and a new prescription
for verapamil. Which of the following information should the nurse include in the
teaching? - ANS "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of
verapamil. The client should increase fiber intake to promote regular bowel function.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include? - ANS Walk for 30 min four times per
week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help
the client prevent osteoporosis.
A nurse is providing teaching to a client who is perimenopausal and has a prescription
for hormone replacement therapy. For which of the following? - ANS Calf pain
Numbness in the arm
Intense headache
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? - ANS Flex
the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the
risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage
system. Which of the following findings is an indication of lung re-expansion? - ANS
Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic
atrial fibrillation. Which of the following values should the nurse identify as a desired
outcome for this therapy? - ANS INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial
infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an
anticoagulant, the medication must be monitored to ensure the anticoagulation is within
the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke,
MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic
range of 2 to 3 for a client who has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury
on the greater trochanter of his left hip. Which of the following instructions should the
nurse include in the teaching? - ANS Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences.
The nurse should also instruct the client to limit the angle of the hips when in a lateral
position to no more than 30°. This positioning prevents direct pressure on the
trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider? - ANS Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is restlessness, which can be
an indication the client is experiencing disequilibrium syndrome. Disequilibrium
syndrome is caused by the rapid removal of electrolytes from the client's blood and can
,lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting,
fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty.
The client is unable to void on the bedpan. Which of the following actions should the
nurse take first? - ANS Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is to assess
the client. Scanning the bladder with a portable ultrasound device will determine the
amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African American
clients at a community center. Which of the following disorders presents the greatest
risk to this group of clients? - ANS Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving? - ANS Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's
status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago.
Which of the following findings should the nurse report to the provider immediately? -
ANS Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is stridor. Stridor can indicate a narrowing airway or
possible obstruction caused by edema or laryngeal spasms. The nurse should report
the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of
the following findings should the nurse report to the provider? - ANS The client reports
back pain
Rationale: The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANS Airborne
, Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such as
tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical
cancer. Which of the following interventions should the nurse include in the plan of
care? - ANS Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room
in case of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of
the following findings is the nurse's priority? - ANS Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is an elevated temperature. An elevated
temperature is a manifestation of excessive thyroid hormone release, or thyroid storm,
due to an increase in metabolic rate. The nurse should report this finding immediately to
the provider because it can lead to seizures and coma.
A nurse is providing discharge teaching about infection prevention to a client who has
AIDS. Which of the following statements by the client indicates understanding of the
teaching? - ANS "I will no longer floss my teeth after brushing my teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
A nurse is providing teaching to a client who has hypertension and a new prescription
for verapamil. Which of the following information should the nurse include in the
teaching? - ANS "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of
verapamil. The client should increase fiber intake to promote regular bowel function.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include? - ANS Walk for 30 min four times per
week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help
the client prevent osteoporosis.
A nurse is providing teaching to a client who is perimenopausal and has a prescription
for hormone replacement therapy. For which of the following? - ANS Calf pain
Numbness in the arm
Intense headache
