ATI RN Adult Medical Surgical (Med-Surg)
Actual and Retake Exam with NGN Package
A nurse is caring for a client who has severe hypertension and is to receive
nitroprusside via continuous IV infusion. Which of the following actions
should the nurse plan to take?
A. Keep client's calcium gluconate at the client's bedside
B. Monitor blood pressure every 2 hr.
C. Limit IV bag from exposure to light.
D. Attach tan inline filter to the IV tubing. - ANSWERSC. Limit IV bag from exposure
to light.
A nurse is caring for a client who is experiencing mild anxiety. Which of
the following findings should the nurse expect?
A. Feelings of dread
B. Heightened perceptual field
C. Rapid speech
D. Purposeless activity - ANSWERSB. Heightened perceptual field
A nurse is reviewing the laboratory report of a client who has been
having lithium carbonate for the past 12 months. The nurse notes a lithium
level of 0.8 mEq/L. Which of the following orders from the provider should the
nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication. - ANSWERSD. Administer the medication.
19. A charge nurse is teaching a newly licensed nurse about clients
designating a health care proxy in situations that require a durable power of
attorney for heal care (DPSHC). Which of the following information should the
charge nurse include?
A. "The proxy should make health care decisions for the client regardless
of the client's ability to do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under
anesthesia."
D. "The proxy should manage legal issues for the client." - ANSWERSC. "The proxy
can make treatment decisions if the client is under anesthesia."
20. A nurse in the PACU is caring for a client who reports nausea. Which of
the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
,D. Monitor the client's vital signs. - ANSWERSA. Turn the client on their side.
21. A nurse is caring for a client who has a history of depression and is
experiencing a situational crisis. Which of the following actions should the
nurse take first?
A. Confirm the client's perception of the event
B. Notify the client's support system
C. Help the client identify personal strengths
D. Teach the client relaxation techniques - ANSWERSA. Confirm the client's
perception of the event
22. A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following actions should the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes. - ANSWERSD. Document the
client's condition every 15 minutes.
24. A charge nurse on a medical-surgical unit is planning assignments for a
licensed practical nurse (LPN) who has been sent from the (Unable to read)
unit due to a staffing shortage. Which of the following client should the nurse
delegate to the LPN?
A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B. A client who sustained a concussion and has unequal pupils.
C. A client who is postoperative following a bowel resection with an NG
tube set to continuous suction.
D. A client who fractured his femur yesterday and is experiencing
shortness of breath. - ANSWERSC. A client who is postoperative following a bowel
resection with an NG tube set to continuous suction.
25. A nurse is working on a surgical unit is developing a care plan for a client who
has paraplegia. The client has an area of nonbankable erythema over his ischium.
Which of the following interventions should the nurse include in the care plan?
A. Place the client upright on a donut-shaped cushion
B. Teach the client to shift his weight every 15 min while sitting
C. Turn and reposition the client every 3 hr while in bed
D. Assess pressure points every 24 hr - ANSWERSA. Place the client upright on a
donut-shaped cushion
A nurse is caring for a client who is dilated to 10 cm and pushing. Which
of the following pain-management is a safe option for the client?
A. Naloxone hydrochloride.
B. Spinal anesthesia.
C. Pudendal block.
D. Butorphanol tartrate. - ANSWERSC. Pudendal block.
27. A nurse is assessing a client who has major depressive disorder. Which of
the following findings should the nurse identify as the priority (Most
,important?)
A. The client changes the subject when future plans are mentioned.
B. The client talks about being in pain constantly.
C. The client sleeping over 12 hr. each day.
D. The client reports giving away personal items. - ANSWERSD. The client reports
giving away personal items.
28. A nurse is providing teaching about immunizations to a client who is
pregnant. The nurse should inform the client that she can receive which of
the following immunizations during pregnancy? (Select all that apply)
A. Varicella vaccine.
B. Inactivated polio vaccine.
C. Tetanus diphtheria and acellular pertussis vaccine
D. Rubella vaccine.
E. Inactivated influenza vaccine. - ANSWERSC,E
29. A nurse is caring for a client who has end-stage kidney disease. The client's
adult child asks the nurse about becoming a living kidney donor for her father. Which
of the following condition in the child's medical history should the nurse identify as a
contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma - ANSWERSC. Hypertension
30. A nurse is providing discharge teaching for a group of clients. The nurse
should recommend a referral to a dietitian
A. A client who has a prescription for warfarin and states "I will need to
limit how much spinach I eat".
B. A client who has gout and states, "I can continue to eat anchovies on
my pizza."
C. A client who has a prescription for spironolactone and states "I will
reduce my intake of foods that contain potassium".
D. A client who has (Unable to read) and states "I'll plan to take my
calcium carbonate with a full glass of water". - ANSWERSB. A client who has gout
and states, "I can continue to eat anchovies on my pizza."
31. A hospice nurse is visiting with the son of a client who has terminal
cancer. The son reports sleeping very little during the past week due to
caring for his mother. Which of the following responses should the nurse
make?
A. "I can give you information about respite care if you are interested."
B. "You should consider taking a sleeping pill before bed each night"
C. "It must be difficult taking care of someone who is terminally ill"
D. "You are doing a great job taking care of your mother" - ANSWERSA. "I can give
you information about respite care if you are interested."
A nurse is assessing a child who is being treated for bacterial pneumonia.
The nurse notes an increase in the child's glucose. The nurse should identify
this finding as an adverse effect of which of the following medications
, A. Methylprednisolone.
B. Ondansetron.
C. Guaifenesin.
D. Amoxicillin. - ANSWERSA. Methylprednisolone.
The nurse is providing teaching about folic acid to a client who is prima
gravida. Which of the following information should the nurse include in the
teaching?
A. "You should take folic acid to decrease the risk of transmitting
infections to your baby"
B. "You should consume a maximum of 300 micrograms of folic acid
every day".
C. "You can increase your dietary intake of folic acid by eating cereals and
citrus fruits".
D. "You can expect your urine to appear red-tingled while taking folic acid
supplements". - ANSWERSC. "You can increase your dietary intake of folic acid by
eating cereals and citrus fruits".
A community health nurse is assessing an adolescent who is pregnant.
Which of the following assessments is the nurse's priority?
A. Social relationship with peers.
B. Plans for attending school while pregnant.
C. Medicaid
D. Understanding of infant care. - ANSWERSC. Medicaid
A nurse manager is planning to teach staff about critical pathways.
Which of the following information should the nurse include?
A. Critical pathways have unlimited timeframe for completion
B. decrease health care costs.
C. critical pathway if variances
D. are used to create the critical pathway. - ANSWERSB. decrease health care
costs.
A nurse is reviewing the medical record of a client who has
schizophrenia. Which of the following should the nurse report to the
provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3
Nurse's notes:
Client reports feeling dizzy when changing positions, Reports weight gain of
1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days
and dry mouth. Client ate 75% of breakfast and reports slightly nauseous.
A. Dietary intake
B. Heart rate.
Actual and Retake Exam with NGN Package
A nurse is caring for a client who has severe hypertension and is to receive
nitroprusside via continuous IV infusion. Which of the following actions
should the nurse plan to take?
A. Keep client's calcium gluconate at the client's bedside
B. Monitor blood pressure every 2 hr.
C. Limit IV bag from exposure to light.
D. Attach tan inline filter to the IV tubing. - ANSWERSC. Limit IV bag from exposure
to light.
A nurse is caring for a client who is experiencing mild anxiety. Which of
the following findings should the nurse expect?
A. Feelings of dread
B. Heightened perceptual field
C. Rapid speech
D. Purposeless activity - ANSWERSB. Heightened perceptual field
A nurse is reviewing the laboratory report of a client who has been
having lithium carbonate for the past 12 months. The nurse notes a lithium
level of 0.8 mEq/L. Which of the following orders from the provider should the
nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication. - ANSWERSD. Administer the medication.
19. A charge nurse is teaching a newly licensed nurse about clients
designating a health care proxy in situations that require a durable power of
attorney for heal care (DPSHC). Which of the following information should the
charge nurse include?
A. "The proxy should make health care decisions for the client regardless
of the client's ability to do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under
anesthesia."
D. "The proxy should manage legal issues for the client." - ANSWERSC. "The proxy
can make treatment decisions if the client is under anesthesia."
20. A nurse in the PACU is caring for a client who reports nausea. Which of
the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
,D. Monitor the client's vital signs. - ANSWERSA. Turn the client on their side.
21. A nurse is caring for a client who has a history of depression and is
experiencing a situational crisis. Which of the following actions should the
nurse take first?
A. Confirm the client's perception of the event
B. Notify the client's support system
C. Help the client identify personal strengths
D. Teach the client relaxation techniques - ANSWERSA. Confirm the client's
perception of the event
22. A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following actions should the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes. - ANSWERSD. Document the
client's condition every 15 minutes.
24. A charge nurse on a medical-surgical unit is planning assignments for a
licensed practical nurse (LPN) who has been sent from the (Unable to read)
unit due to a staffing shortage. Which of the following client should the nurse
delegate to the LPN?
A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B. A client who sustained a concussion and has unequal pupils.
C. A client who is postoperative following a bowel resection with an NG
tube set to continuous suction.
D. A client who fractured his femur yesterday and is experiencing
shortness of breath. - ANSWERSC. A client who is postoperative following a bowel
resection with an NG tube set to continuous suction.
25. A nurse is working on a surgical unit is developing a care plan for a client who
has paraplegia. The client has an area of nonbankable erythema over his ischium.
Which of the following interventions should the nurse include in the care plan?
A. Place the client upright on a donut-shaped cushion
B. Teach the client to shift his weight every 15 min while sitting
C. Turn and reposition the client every 3 hr while in bed
D. Assess pressure points every 24 hr - ANSWERSA. Place the client upright on a
donut-shaped cushion
A nurse is caring for a client who is dilated to 10 cm and pushing. Which
of the following pain-management is a safe option for the client?
A. Naloxone hydrochloride.
B. Spinal anesthesia.
C. Pudendal block.
D. Butorphanol tartrate. - ANSWERSC. Pudendal block.
27. A nurse is assessing a client who has major depressive disorder. Which of
the following findings should the nurse identify as the priority (Most
,important?)
A. The client changes the subject when future plans are mentioned.
B. The client talks about being in pain constantly.
C. The client sleeping over 12 hr. each day.
D. The client reports giving away personal items. - ANSWERSD. The client reports
giving away personal items.
28. A nurse is providing teaching about immunizations to a client who is
pregnant. The nurse should inform the client that she can receive which of
the following immunizations during pregnancy? (Select all that apply)
A. Varicella vaccine.
B. Inactivated polio vaccine.
C. Tetanus diphtheria and acellular pertussis vaccine
D. Rubella vaccine.
E. Inactivated influenza vaccine. - ANSWERSC,E
29. A nurse is caring for a client who has end-stage kidney disease. The client's
adult child asks the nurse about becoming a living kidney donor for her father. Which
of the following condition in the child's medical history should the nurse identify as a
contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma - ANSWERSC. Hypertension
30. A nurse is providing discharge teaching for a group of clients. The nurse
should recommend a referral to a dietitian
A. A client who has a prescription for warfarin and states "I will need to
limit how much spinach I eat".
B. A client who has gout and states, "I can continue to eat anchovies on
my pizza."
C. A client who has a prescription for spironolactone and states "I will
reduce my intake of foods that contain potassium".
D. A client who has (Unable to read) and states "I'll plan to take my
calcium carbonate with a full glass of water". - ANSWERSB. A client who has gout
and states, "I can continue to eat anchovies on my pizza."
31. A hospice nurse is visiting with the son of a client who has terminal
cancer. The son reports sleeping very little during the past week due to
caring for his mother. Which of the following responses should the nurse
make?
A. "I can give you information about respite care if you are interested."
B. "You should consider taking a sleeping pill before bed each night"
C. "It must be difficult taking care of someone who is terminally ill"
D. "You are doing a great job taking care of your mother" - ANSWERSA. "I can give
you information about respite care if you are interested."
A nurse is assessing a child who is being treated for bacterial pneumonia.
The nurse notes an increase in the child's glucose. The nurse should identify
this finding as an adverse effect of which of the following medications
, A. Methylprednisolone.
B. Ondansetron.
C. Guaifenesin.
D. Amoxicillin. - ANSWERSA. Methylprednisolone.
The nurse is providing teaching about folic acid to a client who is prima
gravida. Which of the following information should the nurse include in the
teaching?
A. "You should take folic acid to decrease the risk of transmitting
infections to your baby"
B. "You should consume a maximum of 300 micrograms of folic acid
every day".
C. "You can increase your dietary intake of folic acid by eating cereals and
citrus fruits".
D. "You can expect your urine to appear red-tingled while taking folic acid
supplements". - ANSWERSC. "You can increase your dietary intake of folic acid by
eating cereals and citrus fruits".
A community health nurse is assessing an adolescent who is pregnant.
Which of the following assessments is the nurse's priority?
A. Social relationship with peers.
B. Plans for attending school while pregnant.
C. Medicaid
D. Understanding of infant care. - ANSWERSC. Medicaid
A nurse manager is planning to teach staff about critical pathways.
Which of the following information should the nurse include?
A. Critical pathways have unlimited timeframe for completion
B. decrease health care costs.
C. critical pathway if variances
D. are used to create the critical pathway. - ANSWERSB. decrease health care
costs.
A nurse is reviewing the medical record of a client who has
schizophrenia. Which of the following should the nurse report to the
provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors.
Exhibit 3
Nurse's notes:
Client reports feeling dizzy when changing positions, Reports weight gain of
1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days
and dry mouth. Client ate 75% of breakfast and reports slightly nauseous.
A. Dietary intake
B. Heart rate.
