ATI RN MEDICAL SURGICAL CMS VERSION B STUDYGUIDE COMPLETE 100
QUESTIONS AND CORRECT ANSWERS GRADED A+
A nurse in the emergency department is evaluating a young adult client
for bacterial meningitis. Which of the following actions should the nurse
take as part of the focused assessment?
a. Run a tongue blade on the outside of the client's sole and note any
flaring of the toes.
b. Tap the client's facial nerve and note any facial twitching.
c. Gently elevate the client's head and note any nuchal rigidity.
d. Strike the client's patellar tendon with a percussion hammer and note
any increase in - ANSWER-c. Gently elevate the client's head and note any
nuchal rigidity.
A nurse is preparing to administer fresh frozen plasma to the client.
Which of the following actions should the nurse take?
a. Administer the transfusion through a 25 gauge saline lock
b. hold the transfusion if the client is actively bleeding
c. administer the plasma immediately after thawing
d. transfuse the plasma over 4 hr - ANSWER-c. administer the plasma
immediately after thawing
A nurse is caring for a client who has a arteriovenous graft. Which of the
following findings indicate adequate circulation of the graft?
,a. palpable thrill
b. normotensive BP
c. absence of a bruit
d. dilated appearance of the graft - ANSWER-a. palpable thrill
A nurse is providing instructions to a client who has primary syphillis.
Which of the following instructions should the nurse include in the
discharge plan?
a. "you will need to take an antiviral medication for 6 months"
b. "you will need three follow up blood tests within 24 months"
c. "you will need cryotherapy for 1-2 weeks"
d. "you will need to be monitored for 15 minutes after receiving each
medication dose - ANSWER-b. "you will need three follow up blood tests
within 24 months"
For each assessment findings, specify if the assessment findings is
consistent with DKA and HHS
- urine ketones
- blood glucose greater than the expected reference range
- creatinine greater than the expected reference range
- blood pH greater than the reference range
- skin turgor - ANSWER-urine ketones: DKA
blood glucose greater than the expected reference range: both
,creatinine greater than the expected reference range: both
blood pH greater than the reference range: DKA
skin turgor: both
A nurse is providing dietary instructions to a client who has
cardiovascular disease. The nurse should identify that which of following
statements by the client indicates an understanding of the teaching?
a. "i will limit my portion of meat to 8 ounces"
b. "i will increase my intake in canned vegetables"
c. "i will use canola oil when making salad dressing
d. "i will drink while milk with my cereal" - ANSWER-c. "i will use canola
oil when making salad dressing
A nurse is providing teaching for a client who has diabetes mellitus about
the self-
administration of insulin. The client has prescriptions for regular and NPH
insulins.
Which of the following statements by the client indicates an understanding
of the
teaching?
a. "I will draw up the regular insulin into the syringe first."
b. "I will shake the NPH vial vigorously before drawing up the insulin."
c. "I will store prefilled syringes in the refrigerator with the needle pointed
downward."
, d. "I will insert the needle at a 15-degree angle." - ANSWER-a. "I will draw
up the regular insulin into the syringe first."
A nurse on a medical-surgical unit is planning care for a client who has
dementia and
a history of wandering. Which of the following actions should the nurse
plan to
implement?
a. Move client to a double room.
b. Use chemical restraints at bedtime.
c. Use a bed alarm.
d. Encourage participation in activities that provide excessive stimulation.
- ANSWER-c. Use a bed alarm.
A nurse is caring for a client who has acute angina. Which of the following
actions should the nurse take first?
a. Measure blood pressure.
b. Administer aspirin.
c. administer nitroglycerin
d. initiate IV access - ANSWER-c. administer nitroglycerin
A nurse is planning care for a client who is postoperative following
insertion of an arteriovenous graft in their left forearm. Which of the
following actions should the nurse
include in the plan of care?
QUESTIONS AND CORRECT ANSWERS GRADED A+
A nurse in the emergency department is evaluating a young adult client
for bacterial meningitis. Which of the following actions should the nurse
take as part of the focused assessment?
a. Run a tongue blade on the outside of the client's sole and note any
flaring of the toes.
b. Tap the client's facial nerve and note any facial twitching.
c. Gently elevate the client's head and note any nuchal rigidity.
d. Strike the client's patellar tendon with a percussion hammer and note
any increase in - ANSWER-c. Gently elevate the client's head and note any
nuchal rigidity.
A nurse is preparing to administer fresh frozen plasma to the client.
Which of the following actions should the nurse take?
a. Administer the transfusion through a 25 gauge saline lock
b. hold the transfusion if the client is actively bleeding
c. administer the plasma immediately after thawing
d. transfuse the plasma over 4 hr - ANSWER-c. administer the plasma
immediately after thawing
A nurse is caring for a client who has a arteriovenous graft. Which of the
following findings indicate adequate circulation of the graft?
,a. palpable thrill
b. normotensive BP
c. absence of a bruit
d. dilated appearance of the graft - ANSWER-a. palpable thrill
A nurse is providing instructions to a client who has primary syphillis.
Which of the following instructions should the nurse include in the
discharge plan?
a. "you will need to take an antiviral medication for 6 months"
b. "you will need three follow up blood tests within 24 months"
c. "you will need cryotherapy for 1-2 weeks"
d. "you will need to be monitored for 15 minutes after receiving each
medication dose - ANSWER-b. "you will need three follow up blood tests
within 24 months"
For each assessment findings, specify if the assessment findings is
consistent with DKA and HHS
- urine ketones
- blood glucose greater than the expected reference range
- creatinine greater than the expected reference range
- blood pH greater than the reference range
- skin turgor - ANSWER-urine ketones: DKA
blood glucose greater than the expected reference range: both
,creatinine greater than the expected reference range: both
blood pH greater than the reference range: DKA
skin turgor: both
A nurse is providing dietary instructions to a client who has
cardiovascular disease. The nurse should identify that which of following
statements by the client indicates an understanding of the teaching?
a. "i will limit my portion of meat to 8 ounces"
b. "i will increase my intake in canned vegetables"
c. "i will use canola oil when making salad dressing
d. "i will drink while milk with my cereal" - ANSWER-c. "i will use canola
oil when making salad dressing
A nurse is providing teaching for a client who has diabetes mellitus about
the self-
administration of insulin. The client has prescriptions for regular and NPH
insulins.
Which of the following statements by the client indicates an understanding
of the
teaching?
a. "I will draw up the regular insulin into the syringe first."
b. "I will shake the NPH vial vigorously before drawing up the insulin."
c. "I will store prefilled syringes in the refrigerator with the needle pointed
downward."
, d. "I will insert the needle at a 15-degree angle." - ANSWER-a. "I will draw
up the regular insulin into the syringe first."
A nurse on a medical-surgical unit is planning care for a client who has
dementia and
a history of wandering. Which of the following actions should the nurse
plan to
implement?
a. Move client to a double room.
b. Use chemical restraints at bedtime.
c. Use a bed alarm.
d. Encourage participation in activities that provide excessive stimulation.
- ANSWER-c. Use a bed alarm.
A nurse is caring for a client who has acute angina. Which of the following
actions should the nurse take first?
a. Measure blood pressure.
b. Administer aspirin.
c. administer nitroglycerin
d. initiate IV access - ANSWER-c. administer nitroglycerin
A nurse is planning care for a client who is postoperative following
insertion of an arteriovenous graft in their left forearm. Which of the
following actions should the nurse
include in the plan of care?
