MED SURG PN ATI EXAM 180 QUESTIONS AND
answers with Rationale ALREADY GRADED A+
LATEST VERSION 2025
A nurse is participating in a health fair for older adult clients. Which of the following vaccines should th
nurse recommend for this age group? - ANS >>Herpes zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and military recruits wh
are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contras
agent. Which of the following laboratory findings should the nurse report to the provider prior to th
procedures? - ANS >>Creatinine 1.9 mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report th
finding to the provider before the client has a CT scan with an IV contrast agent. This finding places th
client at risk for developing contrast-induced nephropathy.
---------------------
Expected ranges:
Calcium (ca) 9 - 10.5 mg/dL
,Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
A nurse is reinforcing teaching about home care with a client who had knee arthroplasty. Which of th
following factors should the nurse identify as an indication that a barrier to learning might be present?
ANS >>The client stops the nurse and asks for pain medication
Rationale:
The nurse should identify that a client who is in pain will not be able to concentrate, which can interfer
with their ability to learn.
A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of the following action
should the nurse take to reduce the risk for aspirations? - ANS >>Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent aspiration.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolen
to manage muscle spasms. Which of the following interventions should the nurse include? - AN
>>Encourage the client to complete ADLs.
Rationale:
The nurse should encourage the client to complete ADLs and provide assistance as needed. Performin
self-care increases the client's independence, strength, and level of functioning.
A nurse is reinforcing about joint protection with a clietn who has an acute exacerbation of rheumatoi
arthritis. Which of the following information should the nurse include in the teaching? - ANS >>Apply col
packs to the inflamed joints
Rationale: The nurse should instruct the client to use both warm and cold packs on inflamed joints t
decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises, which will not inflam
the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their joints.
,A nurse is caring for a client who is schedules for surgery and is experiencing anxiety. Which of th
following interventions should the nurse identify as the priority? - ANS >>Determine the client
understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take is to collect data from
the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforc
necessary teaching, which can help manage their anxiety.
A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendation
should the nurse make? - ANS >>Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritatio
to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the oral mucosa.
Instruct the client to eat foods that are high in protein and calories to increase their caloric intake an
nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation of th
client's oral mucosa.
A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis
Which of teh following interventions should the nurse include when contributing to the plan of care?
ANS >>Apply a mask on the client if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during transport to preven
exposure to others.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities shoul
the nurse recommend to promote sleep? - ANS >>Listen to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental stressors.
, A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke
Which of the following actions should the nurse take first? - ANS >>Implement recommendation from th
speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first interventio
the nurse should include in the plan of care is to implement recommendations from the speech languag
pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk fo
aspiration, provide teaching to the client regarding swallowing techniques, and recommend th
consistency of foods and liquids for the client.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has acervical spina
cord injury. Which of the following interventions should the nurse plan to implement first? - AN
>>Determine the client's daily elimination habits.
Rationale:
The first action the nurse should take when using the nursing process is to collect data on the client
daily bowel elimination habits to establish a routine defecation time.
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstructio
in the descending colon. When listening in the left upper quadrant, the nurse should identify this soun
as which of the following? - ANS >>Hyperactive bowel sounds.
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forwar
through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds abov
the point of the intestinal obstruction as the intestines attempt to propel the blockage forward.
A nurse is assisting with the care of a client who has a newly-inserted closed chest tube. Which of th
following findings should the nurse report to the provider? - ANS >>Chest drainage is greater than 7
mL/hr
Rationale:
The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication an
should be reported to the provider.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit followin
a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - AN
>>Keep the cleint in a side-lying position.
Rationale:
answers with Rationale ALREADY GRADED A+
LATEST VERSION 2025
A nurse is participating in a health fair for older adult clients. Which of the following vaccines should th
nurse recommend for this age group? - ANS >>Herpes zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older.
--------------
The nurse should recommend the meningococcal vaccine to college students and military recruits wh
are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contras
agent. Which of the following laboratory findings should the nurse report to the provider prior to th
procedures? - ANS >>Creatinine 1.9 mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report th
finding to the provider before the client has a CT scan with an IV contrast agent. This finding places th
client at risk for developing contrast-induced nephropathy.
---------------------
Expected ranges:
Calcium (ca) 9 - 10.5 mg/dL
,Sodium (Na) 136 - 145 mEq/L
Potassium (K) 3.5 - 5 mEq/L
A nurse is reinforcing teaching about home care with a client who had knee arthroplasty. Which of th
following factors should the nurse identify as an indication that a barrier to learning might be present?
ANS >>The client stops the nurse and asks for pain medication
Rationale:
The nurse should identify that a client who is in pain will not be able to concentrate, which can interfer
with their ability to learn.
A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of the following action
should the nurse take to reduce the risk for aspirations? - ANS >>Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent aspiration.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolen
to manage muscle spasms. Which of the following interventions should the nurse include? - AN
>>Encourage the client to complete ADLs.
Rationale:
The nurse should encourage the client to complete ADLs and provide assistance as needed. Performin
self-care increases the client's independence, strength, and level of functioning.
A nurse is reinforcing about joint protection with a clietn who has an acute exacerbation of rheumatoi
arthritis. Which of the following information should the nurse include in the teaching? - ANS >>Apply col
packs to the inflamed joints
Rationale: The nurse should instruct the client to use both warm and cold packs on inflamed joints t
decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises, which will not inflam
the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress on larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their joints.
,A nurse is caring for a client who is schedules for surgery and is experiencing anxiety. Which of th
following interventions should the nurse identify as the priority? - ANS >>Determine the client
understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take is to collect data from
the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforc
necessary teaching, which can help manage their anxiety.
A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendation
should the nurse make? - ANS >>Eat soft foods.
Rationale:
The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritatio
to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the oral mucosa.
Instruct the client to eat foods that are high in protein and calories to increase their caloric intake an
nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent irritation of th
client's oral mucosa.
A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis
Which of teh following interventions should the nurse include when contributing to the plan of care?
ANS >>Apply a mask on the client if transport is needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during transport to preven
exposure to others.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities shoul
the nurse recommend to promote sleep? - ANS >>Listen to soft music before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental stressors.
, A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke
Which of the following actions should the nurse take first? - ANS >>Implement recommendation from th
speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first interventio
the nurse should include in the plan of care is to implement recommendations from the speech languag
pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk fo
aspiration, provide teaching to the client regarding swallowing techniques, and recommend th
consistency of foods and liquids for the client.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has acervical spina
cord injury. Which of the following interventions should the nurse plan to implement first? - AN
>>Determine the client's daily elimination habits.
Rationale:
The first action the nurse should take when using the nursing process is to collect data on the client
daily bowel elimination habits to establish a routine defecation time.
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstructio
in the descending colon. When listening in the left upper quadrant, the nurse should identify this soun
as which of the following? - ANS >>Hyperactive bowel sounds.
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forwar
through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds abov
the point of the intestinal obstruction as the intestines attempt to propel the blockage forward.
A nurse is assisting with the care of a client who has a newly-inserted closed chest tube. Which of th
following findings should the nurse report to the provider? - ANS >>Chest drainage is greater than 7
mL/hr
Rationale:
The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication an
should be reported to the provider.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit followin
a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - AN
>>Keep the cleint in a side-lying position.
Rationale:
