ATI Med Surg Proctored EXAM LATEST VERSION 1 WITH
ACTUAL 100 QUESTION AND CORRECT DETAILED ANSWERS
WITH RATIONALES.
A nurse is completing an assessment of an older adult client and notes reddened
areas over the bony prominences, but the client's skin is intact. Which of the
following interventions should the nurse include in the plan of care?
A) Support bony prominences with pillows
B) Massage the reddened areas to promote circulation
C) Apply heat to the reddened areas
D) Position the client in a supine position
Correct Answer: A
Rationale
The nurse should support bony prominences with pillows to relieve pressure and
prevent the development of pressure ulcers. Reddened areas over bony
prominences with intact skin indicate a Stage 1 pressure ulcer. The priority
intervention is to relieve pressure through repositioning and support surfaces.
Option B is incorrect because massaging reddened areas can damage underlying
capillaries and worsen tissue ischemia. Option C is incorrect because applying heat
can increase metabolic demand and tissue damage. Option D is incorrect because
the client should be repositioned frequently, not maintained in a single position.
Therefore, supporting bony prominences with pillows is the appropriate
intervention.
A home health nurse is making an initial visit to a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?
A) Assess the client's ability to perform activities of daily living
B) Evaluate the client's medication regimen
C) Assess the client's home environment for safety hazards
D) Review the client's medical history
Correct Answer: C
,Rationale
The priority action for the nurse is to assess the client's home environment for
safety hazards. Clients with multiple sclerosis are at increased risk for falls and
injury due to mobility impairments and muscle weakness. Ensuring a safe home
environment is the priority to prevent injury. Option A is incorrect while assessing
ADLs is important, safety is the priority. Option B is incorrect while evaluating
medications is important, safety is the priority. Option D is incorrect while
reviewing medical history is important, safety is the priority. Therefore, assessing
the home environment for safety hazards is the priority action.
Emergency and Critical Care
A nurse in the emergency department is assessing a client. Which of the following
actions should the nurse take first? (Click on the "Exhibit" button for additional
information about the client)
A) Initiate airborne precautions
B) Initiate droplet precautions
C) Initiate contact precautions
D) Initiate standard precautions
Correct Answer: A
Rationale
The nurse should initiate airborne precautions first based on the client's
presenting symptoms. Airborne precautions are indicated for clients with
suspected tuberculosis, measles, or varicella. The exhibit likely indicates
symptoms consistent with an airborne-transmissible infection. Option B is
incorrect because droplet precautions are used for infections transmitted by
respiratory droplets. Option C is incorrect because contact precautions are used
for infections transmitted by direct or indirect contact. Option D is incorrect
because standard precautions alone are insufficient for airborne-transmissible
infections. Therefore, initiating airborne precautions is the first action.
,Oncology and Cancer Screening
A nurse is reviewing the medical record of a client to identify risk factors for
colorectal cancer. The nurse should identify which of the following findings as
increasing the client's risk?
A) History of Crohn's disease
B) History of hypertension
C) History of diabetes mellitus
D) History of asthma
Correct Answer: A
Rationale
The nurse should identify a history of Crohn's disease as increasing the client's risk
for colorectal cancer. Inflammatory bowel disease, including Crohn's disease and
ulcerative colitis, is a significant risk factor for colorectal cancer. Option B is
incorrect because hypertension is not a risk factor for colorectal cancer. Option C
is incorrect because diabetes mellitus is a risk factor for some cancers but not
specifically colorectal cancer. Option D is incorrect because asthma is not a risk
factor for colorectal cancer. Therefore, a history of Crohn's disease increases the
client's risk.
A nurse is caring for a client who is scheduled for a mastectomy. The client tells
the nurse, "I'm not sure I want to have a mastectomy." Which of the following
statements should the nurse make?
A) "I can give you additional information about the procedure"
B) "You should go ahead with the surgery"
C) "You should not worry about it"
D) "You are making the right decision"
Correct Answer: A
Rationale
The nurse should offer to provide additional information about the procedure.
, This response respects the client's autonomy and provides support while allowing
the client to make an informed decision. Option B is incorrect because it imposes
the nurse's opinion on the client. Option C is incorrect because it dismisses the
client's concerns. Option D is incorrect because it assumes the client's decision
without addressing concerns. Therefore, offering additional information is the
appropriate response.
Alternative Therapies
A nurse is caring for a client who is receiving chemotherapy and requests
information about acupuncture to relieve some of the side effects. Which of the
following findings should the nurse identify as a contraindication to receiving this
alternative therapy?
A) Lymphedema
B) Nausea
C) Fatigue
D) Neuropathy
Correct Answer: A
Rationale
The nurse should identify lymphedema as a contraindication to acupuncture.
Acupuncture involves the insertion of needles into the skin, which can increase
the risk of infection and worsen lymphedema. Option B is incorrect because
acupuncture may help relieve nausea. Option C is incorrect because acupuncture
may help relieve fatigue. Option D is incorrect because acupuncture may help
relieve neuropathy. Therefore, lymphedema is a contraindication to acupuncture.
Intravenous Therapy
ACTUAL 100 QUESTION AND CORRECT DETAILED ANSWERS
WITH RATIONALES.
A nurse is completing an assessment of an older adult client and notes reddened
areas over the bony prominences, but the client's skin is intact. Which of the
following interventions should the nurse include in the plan of care?
A) Support bony prominences with pillows
B) Massage the reddened areas to promote circulation
C) Apply heat to the reddened areas
D) Position the client in a supine position
Correct Answer: A
Rationale
The nurse should support bony prominences with pillows to relieve pressure and
prevent the development of pressure ulcers. Reddened areas over bony
prominences with intact skin indicate a Stage 1 pressure ulcer. The priority
intervention is to relieve pressure through repositioning and support surfaces.
Option B is incorrect because massaging reddened areas can damage underlying
capillaries and worsen tissue ischemia. Option C is incorrect because applying heat
can increase metabolic demand and tissue damage. Option D is incorrect because
the client should be repositioned frequently, not maintained in a single position.
Therefore, supporting bony prominences with pillows is the appropriate
intervention.
A home health nurse is making an initial visit to a client who has multiple sclerosis.
Which of the following actions is the priority for the nurse to take?
A) Assess the client's ability to perform activities of daily living
B) Evaluate the client's medication regimen
C) Assess the client's home environment for safety hazards
D) Review the client's medical history
Correct Answer: C
,Rationale
The priority action for the nurse is to assess the client's home environment for
safety hazards. Clients with multiple sclerosis are at increased risk for falls and
injury due to mobility impairments and muscle weakness. Ensuring a safe home
environment is the priority to prevent injury. Option A is incorrect while assessing
ADLs is important, safety is the priority. Option B is incorrect while evaluating
medications is important, safety is the priority. Option D is incorrect while
reviewing medical history is important, safety is the priority. Therefore, assessing
the home environment for safety hazards is the priority action.
Emergency and Critical Care
A nurse in the emergency department is assessing a client. Which of the following
actions should the nurse take first? (Click on the "Exhibit" button for additional
information about the client)
A) Initiate airborne precautions
B) Initiate droplet precautions
C) Initiate contact precautions
D) Initiate standard precautions
Correct Answer: A
Rationale
The nurse should initiate airborne precautions first based on the client's
presenting symptoms. Airborne precautions are indicated for clients with
suspected tuberculosis, measles, or varicella. The exhibit likely indicates
symptoms consistent with an airborne-transmissible infection. Option B is
incorrect because droplet precautions are used for infections transmitted by
respiratory droplets. Option C is incorrect because contact precautions are used
for infections transmitted by direct or indirect contact. Option D is incorrect
because standard precautions alone are insufficient for airborne-transmissible
infections. Therefore, initiating airborne precautions is the first action.
,Oncology and Cancer Screening
A nurse is reviewing the medical record of a client to identify risk factors for
colorectal cancer. The nurse should identify which of the following findings as
increasing the client's risk?
A) History of Crohn's disease
B) History of hypertension
C) History of diabetes mellitus
D) History of asthma
Correct Answer: A
Rationale
The nurse should identify a history of Crohn's disease as increasing the client's risk
for colorectal cancer. Inflammatory bowel disease, including Crohn's disease and
ulcerative colitis, is a significant risk factor for colorectal cancer. Option B is
incorrect because hypertension is not a risk factor for colorectal cancer. Option C
is incorrect because diabetes mellitus is a risk factor for some cancers but not
specifically colorectal cancer. Option D is incorrect because asthma is not a risk
factor for colorectal cancer. Therefore, a history of Crohn's disease increases the
client's risk.
A nurse is caring for a client who is scheduled for a mastectomy. The client tells
the nurse, "I'm not sure I want to have a mastectomy." Which of the following
statements should the nurse make?
A) "I can give you additional information about the procedure"
B) "You should go ahead with the surgery"
C) "You should not worry about it"
D) "You are making the right decision"
Correct Answer: A
Rationale
The nurse should offer to provide additional information about the procedure.
, This response respects the client's autonomy and provides support while allowing
the client to make an informed decision. Option B is incorrect because it imposes
the nurse's opinion on the client. Option C is incorrect because it dismisses the
client's concerns. Option D is incorrect because it assumes the client's decision
without addressing concerns. Therefore, offering additional information is the
appropriate response.
Alternative Therapies
A nurse is caring for a client who is receiving chemotherapy and requests
information about acupuncture to relieve some of the side effects. Which of the
following findings should the nurse identify as a contraindication to receiving this
alternative therapy?
A) Lymphedema
B) Nausea
C) Fatigue
D) Neuropathy
Correct Answer: A
Rationale
The nurse should identify lymphedema as a contraindication to acupuncture.
Acupuncture involves the insertion of needles into the skin, which can increase
the risk of infection and worsen lymphedema. Option B is incorrect because
acupuncture may help relieve nausea. Option C is incorrect because acupuncture
may help relieve fatigue. Option D is incorrect because acupuncture may help
relieve neuropathy. Therefore, lymphedema is a contraindication to acupuncture.
Intravenous Therapy
