ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025 /RN ADULT MED
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
1. A nurse is providing postoperative teach- Flex the foot every hour when awake.
ing for a client who had a total knee Rationale: The nurse should instruct the client
arthroplasty. Which of the following in- to flex the foot every hour to reduce the risk
structions should the nurse include? for thromboembolism and promote venous
return.
2. A nurse is caring for a client who Bubbling in the water seal chamber has
has a pneumothorax and a closed-chest ceased.
drainage system. Which of the following Rationale: Bubbling in the water seal chamber
findings is an indication of lung re-expan- ceases when the lung re-expands.
sion?
3. A nurse is reviewing the medical record of INR 2.5
a client who is taking warfarin for chronic Rationale: Clients receive warfarin therapy to
atrial fibrillation. Which of the following decrease the risk of stroke, myocardial in-
values should the nurse identify as a de- farction (MI), or pulmonary emboli (PE) from
sired outcome for this therapy? blood clots. Since warfarin is an anticoagu-
lant, the medication must be monitored to
ensure the anticoagulation is within the ther-
apeutic 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.
4. A home health nurse is providing teaching Change position every hour
to a client who has a stage 1 pressure Rationale: Changing position every 1 to 2 hr
injury on the greater trochanter of his left decreases pressure on bony prominences.
hip. Which of the following instructions The nurse should also instruct the client to
should the nurse include in the teaching? limit the angle of the hips when in a lateral
, ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025 /RN ADULT MED
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
position to no more than 30°. This positioning
prevents direct pressure on the trochanter.
5. A nurse is assessing a client following the Restlessness
completion of hemodialysis. Which of the Rationale: Using the urgent vs. nonurgent ap-
following findings is the nurse's priority to proach to client care, the nurse should de-
report to the provider? termine that the priority finding to report to
the provider is restlessness, which can be
an indication the client is experiencing dis-
equilibrium syndrome. Disequilibrium syn-
drome is caused by the rapid removal of elec-
trolytes from the client's blood and can lead
to dysrhythmias or seizures. Other manifesta-
tions include nausea, vomiting, fatigue, and
headache.
6. A nurse is caring for a client who is 8 hr Scan the bladder with a portable ultrasound.
postoperative following a total hip arthro- Rationale: The first action the nurse should
plasty. The client is unable to void on the take using the nursing process is to assess the
bedpan. Which of the following actions client. Scanning the bladder with a portable
should the nurse take first? ultrasound device will determine the amount
of urine in the bladder
7. A nurse is planning a health promotional Hypertension
presentation for a group of African Amer- Rationale: When using the safety/risk reduc-
ican clients at a community center. Which tion approach to client care, the nurse should
of the following disorders presents the determine that the disorder with the greatest
greatest risk to this group of clients? risk for this group of clients is hypertension.
The prevalence of hypertension is highest
, ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025 /RN ADULT MED
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
among African American clients, followed by
Caucasian clients, and then Hispanic clients.
8. A nurse is caring for a client who has DKA. Glucose 272 mg/dL
Which of the following findings should in- Rationale: A glucose reading less than 300
dicate to the nurse that the client's condi- mg/dL indicates improvement in the client's
tion is improving? status.
9. A nurse is caring for a client following Stridor
extubation of an endotracheal tube 10 Rationale: Using the urgent vs. nonurgent ap-
min. ago. Which of the following findings proach to client care, the nurse should deter-
should the nurse report to the provider mine that the priority finding is stridor. Stridor
immediately? 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.
10. A nurse is caring for a client who had a The client reports back pain
nephrostomy tube inserted 112 hr ago. Rationale: The nurse should notify the
Which of the following findings should the provider if the client reports back pain, which
nurse report to the provider? can indicate that the nephrostomy tube is dis-
lodged or clogged.
11. A nurse is admitting a client who has Airborne
active TB. Which of the following types Rationale: Airborne precautions are required
of transmission precautions should the for clients who have infections due to mi-
nurse initiate? cro-organisms that can remain suspended in
air for lengthy periods of time, such as tuber-
culosis, measles, varicella, and disseminated
varicella zoster.
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
1. A nurse is providing postoperative teach- Flex the foot every hour when awake.
ing for a client who had a total knee Rationale: The nurse should instruct the client
arthroplasty. Which of the following in- to flex the foot every hour to reduce the risk
structions should the nurse include? for thromboembolism and promote venous
return.
2. A nurse is caring for a client who Bubbling in the water seal chamber has
has a pneumothorax and a closed-chest ceased.
drainage system. Which of the following Rationale: Bubbling in the water seal chamber
findings is an indication of lung re-expan- ceases when the lung re-expands.
sion?
3. A nurse is reviewing the medical record of INR 2.5
a client who is taking warfarin for chronic Rationale: Clients receive warfarin therapy to
atrial fibrillation. Which of the following decrease the risk of stroke, myocardial in-
values should the nurse identify as a de- farction (MI), or pulmonary emboli (PE) from
sired outcome for this therapy? blood clots. Since warfarin is an anticoagu-
lant, the medication must be monitored to
ensure the anticoagulation is within the ther-
apeutic 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.
4. A home health nurse is providing teaching Change position every hour
to a client who has a stage 1 pressure Rationale: Changing position every 1 to 2 hr
injury on the greater trochanter of his left decreases pressure on bony prominences.
hip. Which of the following instructions The nurse should also instruct the client to
should the nurse include in the teaching? limit the angle of the hips when in a lateral
, ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025 /RN ADULT MED
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
position to no more than 30°. This positioning
prevents direct pressure on the trochanter.
5. A nurse is assessing a client following the Restlessness
completion of hemodialysis. Which of the Rationale: Using the urgent vs. nonurgent ap-
following findings is the nurse's priority to proach to client care, the nurse should de-
report to the provider? termine that the priority finding to report to
the provider is restlessness, which can be
an indication the client is experiencing dis-
equilibrium syndrome. Disequilibrium syn-
drome is caused by the rapid removal of elec-
trolytes from the client's blood and can lead
to dysrhythmias or seizures. Other manifesta-
tions include nausea, vomiting, fatigue, and
headache.
6. A nurse is caring for a client who is 8 hr Scan the bladder with a portable ultrasound.
postoperative following a total hip arthro- Rationale: The first action the nurse should
plasty. The client is unable to void on the take using the nursing process is to assess the
bedpan. Which of the following actions client. Scanning the bladder with a portable
should the nurse take first? ultrasound device will determine the amount
of urine in the bladder
7. A nurse is planning a health promotional Hypertension
presentation for a group of African Amer- Rationale: When using the safety/risk reduc-
ican clients at a community center. Which tion approach to client care, the nurse should
of the following disorders presents the determine that the disorder with the greatest
greatest risk to this group of clients? risk for this group of clients is hypertension.
The prevalence of hypertension is highest
, ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025 /RN ADULT MED
ICAL SURGICAL NURSING ACTUAL EXAM TEST BANK 150 QUESTIONS AN
CORRECT DETAILED ANSWERS
Study online at https://quizlet.com/_fg07p0
among African American clients, followed by
Caucasian clients, and then Hispanic clients.
8. A nurse is caring for a client who has DKA. Glucose 272 mg/dL
Which of the following findings should in- Rationale: A glucose reading less than 300
dicate to the nurse that the client's condi- mg/dL indicates improvement in the client's
tion is improving? status.
9. A nurse is caring for a client following Stridor
extubation of an endotracheal tube 10 Rationale: Using the urgent vs. nonurgent ap-
min. ago. Which of the following findings proach to client care, the nurse should deter-
should the nurse report to the provider mine that the priority finding is stridor. Stridor
immediately? 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.
10. A nurse is caring for a client who had a The client reports back pain
nephrostomy tube inserted 112 hr ago. Rationale: The nurse should notify the
Which of the following findings should the provider if the client reports back pain, which
nurse report to the provider? can indicate that the nephrostomy tube is dis-
lodged or clogged.
11. A nurse is admitting a client who has Airborne
active TB. Which of the following types Rationale: Airborne precautions are required
of transmission precautions should the for clients who have infections due to mi-
nurse initiate? cro-organisms that can remain suspended in
air for lengthy periods of time, such as tuber-
culosis, measles, varicella, and disseminated
varicella zoster.
