ATI EXIT EXAM MED SURG II 2025
QUESTIONS AND ANSWERS |100%
SOLVED
A nurse is caring for a client who is postprocedure following a lumbar puncture
and reports a throbbing headache when sitting upright. Which of the following
actions should the nurse take? (Select all that apply).
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises. -
....ANSWER ...-B. Assist the client to a supine position.
C. Administer an opioid medication.
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,D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which can
relieve a headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of
headache pain. (D) The nurse should encourage increased fluid intake to maintain
a positive fluid balance, which can relieve a headache following a lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should
monitor the client for which of the following complications related to the
ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - ....ANSWER ...-B. Infection
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,Rationale: The nurse should monitor a client who has a ventriculostomy for
infection, which is a complication. The nurse should use strict asepsis to avoid this
life-threatening condition, which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using the
Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks
incoherently, and moves his extremities when pain is applied. Which of the
following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ....ANSWER ...-B. E3 + V4 + M4 = 11
Rationale: The client's score is calculated correctly, indicating moderate head injury.
E3 represents opening eyes secondary to voice stimulation, V4 represents the
verbal conversation that is incoherent and disoriented and M4 represents motor
response as general withdrawal to pain.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply).
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning." - ....ANSWER ...-A. "I think I might
be pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
Rationale: (A) The nurse should report the client's statement of possible pregnancy
to the provider because the contrast dye can place the fetus at risk. (B) The nurse
should report that the client is taking warfarin to the provider due to the potential
for bleeding following angiography (D) The nurse should report a clients report of
allergy to shrimp, which is a shellfish, to the provider due to a potential allergic
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
QUESTIONS AND ANSWERS |100%
SOLVED
A nurse is caring for a client who is postprocedure following a lumbar puncture
and reports a throbbing headache when sitting upright. Which of the following
actions should the nurse take? (Select all that apply).
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises. -
....ANSWER ...-B. Assist the client to a supine position.
C. Administer an opioid medication.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1
,D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which can
relieve a headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of
headache pain. (D) The nurse should encourage increased fluid intake to maintain
a positive fluid balance, which can relieve a headache following a lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should
monitor the client for which of the following complications related to the
ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - ....ANSWER ...-B. Infection
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
,Rationale: The nurse should monitor a client who has a ventriculostomy for
infection, which is a complication. The nurse should use strict asepsis to avoid this
life-threatening condition, which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using the
Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks
incoherently, and moves his extremities when pain is applied. Which of the
following GCS scores should the nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ....ANSWER ...-B. E3 + V4 + M4 = 11
Rationale: The client's score is calculated correctly, indicating moderate head injury.
E3 represents opening eyes secondary to voice stimulation, V4 represents the
verbal conversation that is incoherent and disoriented and M4 represents motor
response as general withdrawal to pain.
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply).
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning." - ....ANSWER ...-A. "I think I might
be pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
Rationale: (A) The nurse should report the client's statement of possible pregnancy
to the provider because the contrast dye can place the fetus at risk. (B) The nurse
should report that the client is taking warfarin to the provider due to the potential
for bleeding following angiography (D) The nurse should report a clients report of
allergy to shrimp, which is a shellfish, to the provider due to a potential allergic
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
