ATI MED SURG EXAM RETAKE 2021
2022 1.A nurse is collecting data from a client who
emphysema. Which of the following findings should the nurse expect? (Select
all that has
apply.)
1)
Dyspnea
2) Barrel
chest
3) Clubbing of the
fingers
4
) Shallow respirations
INCORRECT
5)
Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have
inadequate
emphysemaoxygendue to exchange in the
lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their
elasticity, and the diaphragm becomes permanently flattened by overdistention
of the
lungs. The muscles of the rib cage also become rigid, and the ribs flare
outward. This
Clubbing
produces the of barrel
the fingers is correct.
chest typical Air is trapped
of emphysema in the lungs due to their
clients.
lack of
elasticity, which decreases oxygenation. Clubbing results from these chronic low
blood-
Shallow respirations is correct. Clients who have emphysema lose lung
oxygen levels.
elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart
tries to
compensate for less oxygen being delivered to the tissues.
1. A nurse is caring for a client who has Cushing's syndrome. Which of the
following
clinical manifestations should the nurse expect to observe? (Select all that
1 ) Buffalo hump
apply.)
2) Purple
striations
3
) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese
Buffalo hump is correct. Cushing's syndrome is a disease caused by an
extremities
increased
Answer Rationale:
production of cortisol or by excessive use of corticosteroids. Buffalo hump, a
collection
of fat between the shoulders, is a common manifestation of Cushing's
syndrome.Purple
striations is correct. Purple striations on the skin of the abdomen, thighs,
and breasts
are a common manifestation of Cushing's syndrome. This is due to the
collection of
body fat in these areas.Moon face is correct. Moon face is a common
manifestation of
,Cushing's syndrome. Clients who have this manifestation present with a round,
red, full
face.Tremors is incorrect. Tremors are not a common finding of Cushing's
syndrome.Obese extremities is incorrect. Clients who have Cushing's
syndrome
have truncal obesity, a protuberant abdomen, with thin extremities, which is due
2. A nurse is assisting with the care of a client immediately following a lumbar
to an
puncture.
alteration in protein metabolism.
Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid
intake.
2) Monitor the puncture site for
hematoma.
INCORRECT
3) Insert a urinary
catheter.
INCORRECT
4) Elevate the client’s head of
bed.
INCORRECT
5) Apply a cervical collar to the
client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage
fluids, unless
contraindicated, to replace the cerebrospinal fluid that was removed
during the
Monitor
procedurethe andpuncture
reduce thesite
riskfor
for a headache.
hematoma is correct. The nurse
should monitor
and report a hematoma at the insertion site because this can indicate
Insert a urinary catheter is incorrect. There is no indication for a urinary
bleeding.
catheter
insertion.
Elevate the client’s head of bed is incorrect. The client should remain
flat in bed
for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no
indication for a
cervical collar for this client.
3. A nurse is reinforcing pre-operative teaching for a client who is scheduled for
and is to take hydroxyzine preoperatively. Which of the following effects
surgery
of the
medication should the nurse include in the teaching? (Select all that
1 ) Decreasing
apply.)
anxiety
2
) Controlling
INCORRECT
emesis
3) Relaxing skeletal
muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for
pain relief
Answer Rationale:
,Decreasing anxiety is correct. The nurse should include that hydroxyzine
is an
effective antianxiety agent and is used to decrease anxiety in surgical clients as
well as
Controlling
in persons withemesis is correct.
moderate anxiety.The nurse should include that
hydroxyzine is an
effective antiemetic and is used to control nausea and vomiting in pre- and
postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize
benzodiazepines, such as diazepam (Valium), are used to produce skeletal
muscle
relaxation.
Preventing surgical site infections is incorrect. The nurse should
instruct the client
that antibiotics administered prior to surgery are used to diminish the risk of
surgical
Reducing thehydroxyzine,
site infections; amount ofan narcotics needed
antiemetic, for
does not pain
have anyrelief
effectis
oncorrect.
bacteria.
Hydroxyzine
increases the effects of narcotic pain medications. The nurse should instruct the
client
that when it is used for surgical clients, narcotic requirements may be
4. A nurse is reinforcing teaching with a client who has type 2 diabetes
significantly
nurse determines
mellitus. The that teaching has been effective when the client identifies
reduced.
which of
the following manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry
vision
3
) Tachycardia
INCORRECT
4)
5)Polydipsia
Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes
polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include
blurry vision,
tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors,
anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes
polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors,
anxiety, irritability, headache, and hypotension.
5. A nurse is collecting data from a client who has an exacerbation of gout. Which
of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
, 2) Erythema
3) Tophi
4) Tight
skin
INCORRECT
5) Symmetrical joint
pain
Answer Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation
of gout.
Erythema is correct. Redness over the affected joints is a classic
manifestation of
gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules
that form
in subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic
manifestation of
gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a
manifestation of
rheumatoid arthritis, not gout.
6. A nurse is assisting in the plan of care for a client who had surgery for a
obstruction.
bowel The client has a nasogastric tube in place. Which of the following
actions
should the nurse include in the client's plan of care? (Select all that apply.)
1) Perform leg exercises every
2 hr.
2) Encourage hourly use of an incentive spirometer while
awake.
3
) Document the color, consistency, and amount of nasogastric
INCORRECT
drainage.
4) Irrigate the nasogastric tube every 4
to 8 hr.
INCORRECT
5) Maintain bed rest for 48 hr following
surgery.
Answer Rationale:
Perform leg exercises every 2 hr is correct. Postoperative clients should
frequently
breakdown.Encourage hourly use of
perform leg exercises, independently or an
withincentive spirometer
assistance, to prevent while
skin
awake is
correct. Postoperative clients should be encouraged to use the incentive
spirometer
ten times each hour while awake to prevent atelectasis.Document the
color,
consistency, and amount of nasogastric drainage is correct.
Documenting the
color, consistency, and amount of nasogastric drainage is appropriate to include
in the
client's plan of care.Irrigate the nasogastric tube every 4 to 8 hr is
incorrect. Following abdominal surgery, the NG tube should not be moved or
irrigated
unless prescribed by the provider.Maintain bed rest for 48 hr following
surgery is
incorrect. Maintaining bed rest following surgery should not be included in
the plan of
care. Early ambulation prevents distention and improves intestinal mobility.
2022 1.A nurse is collecting data from a client who
emphysema. Which of the following findings should the nurse expect? (Select
all that has
apply.)
1)
Dyspnea
2) Barrel
chest
3) Clubbing of the
fingers
4
) Shallow respirations
INCORRECT
5)
Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have
inadequate
emphysemaoxygendue to exchange in the
lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their
elasticity, and the diaphragm becomes permanently flattened by overdistention
of the
lungs. The muscles of the rib cage also become rigid, and the ribs flare
outward. This
Clubbing
produces the of barrel
the fingers is correct.
chest typical Air is trapped
of emphysema in the lungs due to their
clients.
lack of
elasticity, which decreases oxygenation. Clubbing results from these chronic low
blood-
Shallow respirations is correct. Clients who have emphysema lose lung
oxygen levels.
elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart
tries to
compensate for less oxygen being delivered to the tissues.
1. A nurse is caring for a client who has Cushing's syndrome. Which of the
following
clinical manifestations should the nurse expect to observe? (Select all that
1 ) Buffalo hump
apply.)
2) Purple
striations
3
) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese
Buffalo hump is correct. Cushing's syndrome is a disease caused by an
extremities
increased
Answer Rationale:
production of cortisol or by excessive use of corticosteroids. Buffalo hump, a
collection
of fat between the shoulders, is a common manifestation of Cushing's
syndrome.Purple
striations is correct. Purple striations on the skin of the abdomen, thighs,
and breasts
are a common manifestation of Cushing's syndrome. This is due to the
collection of
body fat in these areas.Moon face is correct. Moon face is a common
manifestation of
,Cushing's syndrome. Clients who have this manifestation present with a round,
red, full
face.Tremors is incorrect. Tremors are not a common finding of Cushing's
syndrome.Obese extremities is incorrect. Clients who have Cushing's
syndrome
have truncal obesity, a protuberant abdomen, with thin extremities, which is due
2. A nurse is assisting with the care of a client immediately following a lumbar
to an
puncture.
alteration in protein metabolism.
Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid
intake.
2) Monitor the puncture site for
hematoma.
INCORRECT
3) Insert a urinary
catheter.
INCORRECT
4) Elevate the client’s head of
bed.
INCORRECT
5) Apply a cervical collar to the
client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage
fluids, unless
contraindicated, to replace the cerebrospinal fluid that was removed
during the
Monitor
procedurethe andpuncture
reduce thesite
riskfor
for a headache.
hematoma is correct. The nurse
should monitor
and report a hematoma at the insertion site because this can indicate
Insert a urinary catheter is incorrect. There is no indication for a urinary
bleeding.
catheter
insertion.
Elevate the client’s head of bed is incorrect. The client should remain
flat in bed
for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no
indication for a
cervical collar for this client.
3. A nurse is reinforcing pre-operative teaching for a client who is scheduled for
and is to take hydroxyzine preoperatively. Which of the following effects
surgery
of the
medication should the nurse include in the teaching? (Select all that
1 ) Decreasing
apply.)
anxiety
2
) Controlling
INCORRECT
emesis
3) Relaxing skeletal
muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for
pain relief
Answer Rationale:
,Decreasing anxiety is correct. The nurse should include that hydroxyzine
is an
effective antianxiety agent and is used to decrease anxiety in surgical clients as
well as
Controlling
in persons withemesis is correct.
moderate anxiety.The nurse should include that
hydroxyzine is an
effective antiemetic and is used to control nausea and vomiting in pre- and
postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize
benzodiazepines, such as diazepam (Valium), are used to produce skeletal
muscle
relaxation.
Preventing surgical site infections is incorrect. The nurse should
instruct the client
that antibiotics administered prior to surgery are used to diminish the risk of
surgical
Reducing thehydroxyzine,
site infections; amount ofan narcotics needed
antiemetic, for
does not pain
have anyrelief
effectis
oncorrect.
bacteria.
Hydroxyzine
increases the effects of narcotic pain medications. The nurse should instruct the
client
that when it is used for surgical clients, narcotic requirements may be
4. A nurse is reinforcing teaching with a client who has type 2 diabetes
significantly
nurse determines
mellitus. The that teaching has been effective when the client identifies
reduced.
which of
the following manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry
vision
3
) Tachycardia
INCORRECT
4)
5)Polydipsia
Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes
polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include
blurry vision,
tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors,
anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes
polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors,
anxiety, irritability, headache, and hypotension.
5. A nurse is collecting data from a client who has an exacerbation of gout. Which
of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
, 2) Erythema
3) Tophi
4) Tight
skin
INCORRECT
5) Symmetrical joint
pain
Answer Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation
of gout.
Erythema is correct. Redness over the affected joints is a classic
manifestation of
gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules
that form
in subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic
manifestation of
gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a
manifestation of
rheumatoid arthritis, not gout.
6. A nurse is assisting in the plan of care for a client who had surgery for a
obstruction.
bowel The client has a nasogastric tube in place. Which of the following
actions
should the nurse include in the client's plan of care? (Select all that apply.)
1) Perform leg exercises every
2 hr.
2) Encourage hourly use of an incentive spirometer while
awake.
3
) Document the color, consistency, and amount of nasogastric
INCORRECT
drainage.
4) Irrigate the nasogastric tube every 4
to 8 hr.
INCORRECT
5) Maintain bed rest for 48 hr following
surgery.
Answer Rationale:
Perform leg exercises every 2 hr is correct. Postoperative clients should
frequently
breakdown.Encourage hourly use of
perform leg exercises, independently or an
withincentive spirometer
assistance, to prevent while
skin
awake is
correct. Postoperative clients should be encouraged to use the incentive
spirometer
ten times each hour while awake to prevent atelectasis.Document the
color,
consistency, and amount of nasogastric drainage is correct.
Documenting the
color, consistency, and amount of nasogastric drainage is appropriate to include
in the
client's plan of care.Irrigate the nasogastric tube every 4 to 8 hr is
incorrect. Following abdominal surgery, the NG tube should not be moved or
irrigated
unless prescribed by the provider.Maintain bed rest for 48 hr following
surgery is
incorrect. Maintaining bed rest following surgery should not be included in
the plan of
care. Early ambulation prevents distention and improves intestinal mobility.
