ATI NCLEX Medical Surgical
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following actions should the nurse include in the plan
Provide the client with a means of communication
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration.
Which of the following laboratory results indicates effectiveness of the treatment
Urine Specific Gravity 1.020
**Within the expected range of 1.005-1.030
A nurse is monitoring the laboratory findings for a client who is postoperative following a total
hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased
risk for bleeding
Platelets 80,000
**Normal range is 150,000-400,000
A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle
crash. Which of the following interventions is the nurse's priority while caring for this client
Assist with quad coughing
**The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the
priority is to ensure the client can clear their airway. Apply abdominal pressure as the client
coughs (quad coughing)
, ATI NCLEX Medical Surgical
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
A nurse is caring for a client who is receiving a blood transfusion. Which of the following
findings indicates that the client is experiencing circulatory overload
Dyspnea
**Dyspnea is an indication of possible transfusion-associated circulatory overload, leading to
hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion-related
acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness,
cyanosis, and low BP
A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the
chest. Which of the following indicates an adverse effect of the therapy
Altered taste, **due to the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of
the following actions should the nurse plan to take (select all that apply)
*Obtain pre-transfusion temperature
**Verify the client's blood type with a second nurse
***Use a 20 gauge IV needle for venous access
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the
following BUN levels should the nurse expect
26 mg/dL
, ATI NCLEX Medical Surgical
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
**Normal range is 10-20.
Elevated levels indicate renal disease, dehydration, shock, excessive protein in the diet, sepsis,
glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured
tissues
--
A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload, or
nephrotic syndrome
A nurse is reviewing ECG strips for several clients. Which of the following images should the
nurse identify as A-Fib
Multiple irregular and variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the operating room.
Which of the following items is the priority for the nurse to have available in the client's room
upon admission
Obturator
**The obturator can be inserted in the stoma in the event of dislodgment or decannulation to
maintain an airway until a new trach tube can be placed. For the first 72 hr following the
insertion of a trach, dislodgement or decannulation is considered an emergency
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2
days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following actions should the nurse include in the plan
Provide the client with a means of communication
A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration.
Which of the following laboratory results indicates effectiveness of the treatment
Urine Specific Gravity 1.020
**Within the expected range of 1.005-1.030
A nurse is monitoring the laboratory findings for a client who is postoperative following a total
hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased
risk for bleeding
Platelets 80,000
**Normal range is 150,000-400,000
A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle
crash. Which of the following interventions is the nurse's priority while caring for this client
Assist with quad coughing
**The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the
priority is to ensure the client can clear their airway. Apply abdominal pressure as the client
coughs (quad coughing)
, ATI NCLEX Medical Surgical
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
A nurse is caring for a client who is receiving a blood transfusion. Which of the following
findings indicates that the client is experiencing circulatory overload
Dyspnea
**Dyspnea is an indication of possible transfusion-associated circulatory overload, leading to
hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion-related
acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness,
cyanosis, and low BP
A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the
chest. Which of the following indicates an adverse effect of the therapy
Altered taste, **due to the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of
the following actions should the nurse plan to take (select all that apply)
*Obtain pre-transfusion temperature
**Verify the client's blood type with a second nurse
***Use a 20 gauge IV needle for venous access
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the
following BUN levels should the nurse expect
26 mg/dL
, ATI NCLEX Medical Surgical
Assessment 1 Exam| Questions &
Answers | Grade A (100% Correct)
**Normal range is 10-20.
Elevated levels indicate renal disease, dehydration, shock, excessive protein in the diet, sepsis,
glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured
tissues
--
A low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload, or
nephrotic syndrome
A nurse is reviewing ECG strips for several clients. Which of the following images should the
nurse identify as A-Fib
Multiple irregular and variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the operating room.
Which of the following items is the priority for the nurse to have available in the client's room
upon admission
Obturator
**The obturator can be inserted in the stoma in the event of dislodgment or decannulation to
maintain an airway until a new trach tube can be placed. For the first 72 hr following the
insertion of a trach, dislodgement or decannulation is considered an emergency
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2
days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image
