ATI Med Surge Proctored Exam 2023,
RN 2023 Adult Medical Surgical ATI
Proctored
. A nurse is caring for a client who was admitted with major burns to the head, neck, and
chest. Which of the following complications should the nurse identify as the greatest risk to
the client? - ---------correct answer------Airway obstruction
.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first? - ---------correct answer------Stop the transfusion
.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority? - ---------
correct answer------Evaluate fluid and electrolyte levels.
.A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take? - ---------correct answer------Empty the suction device every 4 hr
.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has
a prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective? - ---------correct
answer------"I feel very sleepy."
.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client's renal
function? - ---------correct answer------Serum creatinine
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from rooms and hallways.
B. Place a monthly calendar in the client's room.
C. Use confrontation to manage the client's behavior.
D. Review the daily schedule with the client every morning. - ---------correct answer------A.
Remove clutter from rooms and hallways.
The nurse should instruct the family member to remove clutter from rooms and hallways so
the client is able to walk without the risk of falling or tripping over objects. Later in the
disease, the client can experience seizures, so cluttered areas could be a risk to the client.
,A home health nurse is inspecting a client's residence for electrical hazards as part of the
agency's quality improvement plan. Which of the following findings should the nurse
identify as a safety hazard?
A. The client's bed has a three-prong plug attached to the electrical cord.
B. A protective cover is inserted into an unused outlet.
C. An IV pump is plugged into an outlet near a sink.
D. An electrical cord is coiled and secured to the floor. - ---------correct answer------C. An IV
pump is plugged into an outlet near a sink
The nurse should plug all electrical appliances into outlets away from wet areas. Water
conducts electricity and places the client at risk for electrocution.
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following data-
collection activities? - ---------correct answer------Checking pupillary responses to light
A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take?
A. Give detailed directions when addressing the client.
B. Provide finger food at mealtime.
C. Use written signs to redirect the client.
D. Seat the client at a large table for meals. - ---------correct answer------B. Provide finger
food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who have
dementia can have difficulty sitting still and tend to wander, which makes weight loss and
malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
A nurse in a provider's office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect? - ---------correct answer------Report of dryness with vaginal intercourse
A nurse in a provider's office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include? - ---------correct answer------Take this medication between meals.
A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the
nurse expect?
A. High lipase
,B. Low urine specific gravity
C. Low hemoglobin
D. High creatine kinase-MB (CK-MB) - ---------correct answer------B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which
affects the specific gravity.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat
stroke. Which of the following actions should the nurse take first?
A. Measure the client's urine specific gravity.
B. Administer oxygen using a high-concentration mask.
C. Initiate gastric lavage with ice water.
D. Immerse the client in cold water. - ---------correct answer------B. Administer oxygen using
a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer
oxygen using a high-concentration mask to promote oxygen perfusion to vital organs.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the
following mechanisms should the nurse identify as responsible for this acid-base imbalance?
A. Breakdown of fatty acids
B. Retention of carbon dioxide
C. Hyperventilation in response to hypoxia
D. Ingestion of large amounts of bicarbonate - ---------correct answer------B. Retention of
carbon dioxide
Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon
, dioxide can result from respiratory depression, inadequate chest expansion, airway
obstruction, or decreased alveolar capillary diffusion.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The
nurse should identify which of the following findings as an indication the client is at risk for
fluid volume deficit?
A. BUN 16 mg/dL
B. Urine output 40 mL every hour for 3 hr
C. Hct 42%
D. Surgical drain output 300 mL during an 8-hr shift - ---------correct answer------D. Surgical
drain output 300 mL during an 8-hr shift
A client who had lumbar spinal surgery should not have more than 250 mL from a drain in
the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid
volume deficit.
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV)
fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that
the IV tubing and needleless connector device are disconnected. Which of the following
actions should the nurse take first?
A. Close the pinch clamp on the CVC.
B. Obtain a prescription for stat ABGs.
C. Place the client in left Trendelenburg position.
D. Check the tubing for placement of a locking adaptor. - ---------correct answer------A. Close
the pinch clamp on the CVC.
The greatest risk to this client is air embolism resulting from accidental disconnection of
the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by
closing the pinch clamp to prevent any further air from entering the system. When an air
embolism occurs, air enters through the central vein into the right ventricle and lodges by
RN 2023 Adult Medical Surgical ATI
Proctored
. A nurse is caring for a client who was admitted with major burns to the head, neck, and
chest. Which of the following complications should the nurse identify as the greatest risk to
the client? - ---------correct answer------Airway obstruction
.A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse
take first? - ---------correct answer------Stop the transfusion
.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis.
The nurse should recognize that which of the following actions is the priority? - ---------
correct answer------Evaluate fluid and electrolyte levels.
.A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should
the nurse take? - ---------correct answer------Empty the suction device every 4 hr
.A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has
a prescription for lorazepam preoperatively. Which of the following statements by the client
should indicate to the nurse that the medication has been effective? - ---------correct
answer------"I feel very sleepy."
.A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which
of the following laboratory values should the nurse review to determine the client's renal
function? - ---------correct answer------Serum creatinine
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include?
A. Remove clutter from rooms and hallways.
B. Place a monthly calendar in the client's room.
C. Use confrontation to manage the client's behavior.
D. Review the daily schedule with the client every morning. - ---------correct answer------A.
Remove clutter from rooms and hallways.
The nurse should instruct the family member to remove clutter from rooms and hallways so
the client is able to walk without the risk of falling or tripping over objects. Later in the
disease, the client can experience seizures, so cluttered areas could be a risk to the client.
,A home health nurse is inspecting a client's residence for electrical hazards as part of the
agency's quality improvement plan. Which of the following findings should the nurse
identify as a safety hazard?
A. The client's bed has a three-prong plug attached to the electrical cord.
B. A protective cover is inserted into an unused outlet.
C. An IV pump is plugged into an outlet near a sink.
D. An electrical cord is coiled and secured to the floor. - ---------correct answer------C. An IV
pump is plugged into an outlet near a sink
The nurse should plug all electrical appliances into outlets away from wet areas. Water
conducts electricity and places the client at risk for electrocution.
A nurse caring for a client at risk for increased intracranial pressure is monitoring the client
for manifestations that indicate that the pressure is increasing. To do this, the nurse should
check the function of the third cranial nerve by performing which of the following data-
collection activities? - ---------correct answer------Checking pupillary responses to light
A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take?
A. Give detailed directions when addressing the client.
B. Provide finger food at mealtime.
C. Use written signs to redirect the client.
D. Seat the client at a large table for meals. - ---------correct answer------B. Provide finger
food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who have
dementia can have difficulty sitting still and tend to wander, which makes weight loss and
malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
A nurse in a provider's office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the
nurse expect? - ---------correct answer------Report of dryness with vaginal intercourse
A nurse in a provider's office is reinforcing teaching with a client who has anemia and has
been taking ferrous gluconate for several weeks. Which of the following instructions should
the nurse include? - ---------correct answer------Take this medication between meals.
A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings
should the
nurse expect?
A. High lipase
,B. Low urine specific gravity
C. Low hemoglobin
D. High creatine kinase-MB (CK-MB) - ---------correct answer------B. Low urine specific gravity
A client who has hyponatremia as a result of diuretic overuse has a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which
affects the specific gravity.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat
stroke. Which of the following actions should the nurse take first?
A. Measure the client's urine specific gravity.
B. Administer oxygen using a high-concentration mask.
C. Initiate gastric lavage with ice water.
D. Immerse the client in cold water. - ---------correct answer------B. Administer oxygen using
a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer
oxygen using a high-concentration mask to promote oxygen perfusion to vital organs.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the
following mechanisms should the nurse identify as responsible for this acid-base imbalance?
A. Breakdown of fatty acids
B. Retention of carbon dioxide
C. Hyperventilation in response to hypoxia
D. Ingestion of large amounts of bicarbonate - ---------correct answer------B. Retention of
carbon dioxide
Respiratory acidosis results from the retention of carbon dioxide. Retention of carbon
, dioxide can result from respiratory depression, inadequate chest expansion, airway
obstruction, or decreased alveolar capillary diffusion.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The
nurse should identify which of the following findings as an indication the client is at risk for
fluid volume deficit?
A. BUN 16 mg/dL
B. Urine output 40 mL every hour for 3 hr
C. Hct 42%
D. Surgical drain output 300 mL during an 8-hr shift - ---------correct answer------D. Surgical
drain output 300 mL during an 8-hr shift
A client who had lumbar spinal surgery should not have more than 250 mL from a drain in
the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid
volume deficit.
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV)
fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that
the IV tubing and needleless connector device are disconnected. Which of the following
actions should the nurse take first?
A. Close the pinch clamp on the CVC.
B. Obtain a prescription for stat ABGs.
C. Place the client in left Trendelenburg position.
D. Check the tubing for placement of a locking adaptor. - ---------correct answer------A. Close
the pinch clamp on the CVC.
The greatest risk to this client is air embolism resulting from accidental disconnection of
the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by
closing the pinch clamp to prevent any further air from entering the system. When an air
embolism occurs, air enters through the central vein into the right ventricle and lodges by
