MED SURG- PROCTORED ATI EXAM
QUESTIONS WITH ACCURATE RIGHT
ANSWERS .
An older adult is brought to an emergency department by a family member. Which of the
following assessment findings should cause the nurse to suspect that the client has hypertonic
dehydration? - Correct Answer -Urine Specific gravity 1.045
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an
increase in osmolarity, which is a manifestation of hypertonic dehydration.
A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To help reduce the risk for migraine headaches, which of the
following foods should the nurse recommend the client avoid? - Correct Answer -Aged
cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine
headaches.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching? - Correct Answer -"You should cut the opening of
the skin barrier one-eight inch wider than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to
minimize irritation of the skin from exposure to urine.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication? - Correct Answer -Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
as an antacid. Calcium supplements can interfere with the metabolism of a number of
1
,medications, including levothyroxine. The nurse should instruct the client to avoid taking
calcium within 4 hr of levothyroxine administration.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify that which of the following findings requires
further assessment? - Correct Answer -History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad? - Correct
Answer -Bradycardia
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing's
triad are severe hypertension and a widened pulse pressure.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take? - Correct Answer -
Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver
the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain
healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
expect? - Correct Answer -Administer an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following
a rattlesnake bite.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing.
The nurse should postpone the testing and report to the provider which of the following
2
, findings? (Click on the "Exhibit" button for additional information about the client). -
Correct Answer -Current medications
The nurse should review the client's medication record and identify medications, including
ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as
prednisone, that can alter the allergy skin test results. These medications can diminish the
client's reaction to the allergens. The nurse should notify the provider and instruct the client
to discontinue prednisone for 2 weeks before allergy skin testing.
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take? - Correct Answer -
Inject the medication into the anterolateral abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the following
findings contribute to delayed wound healing? - Correct Answer -Urine output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which
can delay wound healing.
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump
should be set at how many mL/hr? (Rounding to the nearest whole number.) - Correct
Answer -167 mL/hr
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend? - Correct
Answer -Add cabbage to the diet.
To help reduce the risk for colorectal cancer, the client should consume a diet that is high in
fiber, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage,
cauliflower, and broccoli, are high in fiber.
3
QUESTIONS WITH ACCURATE RIGHT
ANSWERS .
An older adult is brought to an emergency department by a family member. Which of the
following assessment findings should cause the nurse to suspect that the client has hypertonic
dehydration? - Correct Answer -Urine Specific gravity 1.045
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an
increase in osmolarity, which is a manifestation of hypertonic dehydration.
A nurse in a community clinic is caring for a client who reports an increase in the frequency
of migraine headaches. To help reduce the risk for migraine headaches, which of the
following foods should the nurse recommend the client avoid? - Correct Answer -Aged
cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine
headaches.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a
cutaneous diversion procedure to establish a ureterostomy. Which of the following statements
should the nurse include in the teaching? - Correct Answer -"You should cut the opening of
the skin barrier one-eight inch wider than the stoma."
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to
minimize irritation of the skin from exposure to urine.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following supplements
can interfere with the effectiveness of the medication? - Correct Answer -Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
as an antacid. Calcium supplements can interfere with the metabolism of a number of
1
,medications, including levothyroxine. The nurse should instruct the client to avoid taking
calcium within 4 hr of levothyroxine administration.
A nurse is conducting an admission history for a client who is to undergo a CT scan with an
IV contrast agent. The nurse should identify that which of the following findings requires
further assessment? - Correct Answer -History of asthma
A client who has a history of asthma has a greater risk of reacting to the contrast dye used
during the procedure. Other conditions that can result in a reaction to contrast media include
allergies to foods, such as shellfish, eggs, milk, and chocolate.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the
following findings should the nurse identify as a component of Cushing's triad? - Correct
Answer -Bradycardia
A client who has increased intracranial pressure from a traumatic brain injury can develop
bradycardia, which is one component of Cushing's triad. The other components of Cushing's
triad are severe hypertension and a widened pulse pressure.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a
pressure injury. Which of the following actions should the nurse take? - Correct Answer -
Use a 30-mL syringe
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19- gauge catheter to deliver
the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain
healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the
expect? - Correct Answer -Administer an opioid analgesic to the client.
The nurse should expect a prescription for an opioid analgesic to promote comfort following
a rattlesnake bite.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing.
The nurse should postpone the testing and report to the provider which of the following
2
, findings? (Click on the "Exhibit" button for additional information about the client). -
Correct Answer -Current medications
The nurse should review the client's medication record and identify medications, including
ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as
prednisone, that can alter the allergy skin test results. These medications can diminish the
client's reaction to the allergens. The nurse should notify the provider and instruct the client
to discontinue prednisone for 2 weeks before allergy skin testing.
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin
subcutaneous. Which of the following actions should the nurse take? - Correct Answer -
Inject the medication into the anterolateral abdominal wall.
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
to enhance medication absorption and prevent hematoma formation.
A nurse is caring for a client who has a stage III pressure injury. Which if the following
findings contribute to delayed wound healing? - Correct Answer -Urine output 25 mL/hr
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which
can delay wound healing.
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN).
The client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump
should be set at how many mL/hr? (Rounding to the nearest whole number.) - Correct
Answer -167 mL/hr
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate
this risk, which of the following dietary alterations should the nurse recommend? - Correct
Answer -Add cabbage to the diet.
To help reduce the risk for colorectal cancer, the client should consume a diet that is high in
fiber, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage,
cauliflower, and broccoli, are high in fiber.
3
