ATI Med Surg Proctored Exam Practice Qs
A charge nurse is observing a newly licensed nurse administer an IV medication to a client who
has an implanted venous access port. Which of the following observations requires intervention
by the charge nurse?
A. A dressing is not applied to the port site after use.
B. A 22-gauge non-coring needle is used to access the port.
C. Blood return is noted prior to administering the medication.
D. A solution of 5 mL heparin 1,000 units/mL has been prepared. - ANS-D. A solution of 5 mL
heparin 1,000 units/mL has been prepared.
Implanted ports should be flushed after each use and at least once a month when not in use.
This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent
the formation of blood clots in the catheter, which would disrupt the proper functioning of the
catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires
intervention by the charge nurse.
A client is being discharged home with oxygen therapy delivered through a nasal cannula.
Which of the following instructions should the nurse provide to the client and family members?
A. Use battery-operated equipment for personal care.
B. Apply mineral oil to protect the facial skin from irritation.
C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity. - ANS-D. Wear cotton clothing to avoid static
electricity.
The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly
combustible gas. The use of oxygen in high concentrations has great combustion potential and
readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily
cause a fire in a client's room if it contacts a spark.
A nurse in an emergency department is assessing a client who sustained a fall off of a roof.
Which of the following findings should the nurse identify as an indication of a basilar skull
fracture?
A. Depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp - ANS-B. Clear fluid coming from the nares
,Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar
skull fracture.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of
the following findings should the nurse report to the provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg - ANS-C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients
who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat
emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter
into the systemic circulation and are deposited in the lungs. The nurse should immediately notify
the provider because the client could progress to acute respiratory failure.
A nurse is assessing a client who has cholecystitis. Which of the following findings should the
nurse expect?
A. Blumberg's sign
B. Ascites
C. Gastrointestinal bleeding
D. Kehr's sign - ANS-A. Blumberg's sign
The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has
cholecystitis. This response can be an indication of peritoneal inflammation.
:B. The nurse should expect to find ascites in a client who has chronic pancreatitis or pancreatic
cancer.
C. The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic
cancer.
D. The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should
the nurse expect?
A. Nonproductive cough, fever, and shortness of breath
B. Lesions on the retina that produce blurred vision
C. Onset of progressive dementia
D. Reddish-purple skin lesions - ANS-D. Reddish-purple skin lesions
, Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented
multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are
treated with radiation and/or chemotherapy.
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the
right ankle. Which of the following findings should the nurse expect in the client's affected
extremity?
A. Absent pedal pulses
B. Ankle swelling
C. Hair loss
D. Skin atrophy - ANS-B. Ankle swelling
The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency
due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.
A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy.
Which of the following findings should the nurse report to the provider?
A. Hypoactive bowel sounds
B. Indwelling urinary catheter output of 25 mL/hr
C. Heart rate of 96/min
D. Serous drainage at the surgical incision site - ANS-B. Indwelling urinary catheter output of 25
mL/hr
The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate
hypovolemia or renal complication.
A nurse is assessing a client who sustained superficial partial-thickness and deep
partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the
provider?
A. Edema in the burned extremities
B. Severe pain at the burn sites
C. Urine output of 30 mL/hr
D. Temperature of 39.1°C (102.4°F) - ANS-D. Temperature of 39.1°C (102.4°F)
An elevated temperature is an indication of infection, and the nurse should report this finding to
the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are
relatively pathogen-free. On approximately the third day following the injury, early colonization of
the wound surface by gram-negative organisms changes to predominantly gram-positive
opportunistic organisms.
A charge nurse is observing a newly licensed nurse administer an IV medication to a client who
has an implanted venous access port. Which of the following observations requires intervention
by the charge nurse?
A. A dressing is not applied to the port site after use.
B. A 22-gauge non-coring needle is used to access the port.
C. Blood return is noted prior to administering the medication.
D. A solution of 5 mL heparin 1,000 units/mL has been prepared. - ANS-D. A solution of 5 mL
heparin 1,000 units/mL has been prepared.
Implanted ports should be flushed after each use and at least once a month when not in use.
This practice is sometimes referred to as "locking" or "de-accessing." It is performed to prevent
the formation of blood clots in the catheter, which would disrupt the proper functioning of the
catheter. The solution of 5 mL heparin should be 100 units/mL; therefore, this action requires
intervention by the charge nurse.
A client is being discharged home with oxygen therapy delivered through a nasal cannula.
Which of the following instructions should the nurse provide to the client and family members?
A. Use battery-operated equipment for personal care.
B. Apply mineral oil to protect the facial skin from irritation.
C. Remove the television set from the client's bedroom.
D. Wear cotton clothing to avoid static electricity. - ANS-D. Wear cotton clothing to avoid static
electricity.
The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly
combustible gas. The use of oxygen in high concentrations has great combustion potential and
readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily
cause a fire in a client's room if it contacts a spark.
A nurse in an emergency department is assessing a client who sustained a fall off of a roof.
Which of the following findings should the nurse identify as an indication of a basilar skull
fracture?
A. Depressed fracture of the forehead
B. Clear fluid coming from the nares
C. Motor loss on one side of the body
D. Bleeding from the top of the scalp - ANS-B. Clear fluid coming from the nares
,Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar
skull fracture.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of
the following findings should the nurse report to the provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg - ANS-C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients
who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat
emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter
into the systemic circulation and are deposited in the lungs. The nurse should immediately notify
the provider because the client could progress to acute respiratory failure.
A nurse is assessing a client who has cholecystitis. Which of the following findings should the
nurse expect?
A. Blumberg's sign
B. Ascites
C. Gastrointestinal bleeding
D. Kehr's sign - ANS-A. Blumberg's sign
The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has
cholecystitis. This response can be an indication of peritoneal inflammation.
:B. The nurse should expect to find ascites in a client who has chronic pancreatitis or pancreatic
cancer.
C. The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic
cancer.
D. The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.
A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should
the nurse expect?
A. Nonproductive cough, fever, and shortness of breath
B. Lesions on the retina that produce blurred vision
C. Onset of progressive dementia
D. Reddish-purple skin lesions - ANS-D. Reddish-purple skin lesions
, Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented
multicentric lesions that can be firm, flat, raised, or nodular. Following a biopsy, the lesions are
treated with radiation and/or chemotherapy.
A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the
right ankle. Which of the following findings should the nurse expect in the client's affected
extremity?
A. Absent pedal pulses
B. Ankle swelling
C. Hair loss
D. Skin atrophy - ANS-B. Ankle swelling
The nurse should identify that swelling of the ankle is a manifestation of venous insufficiency
due to poor venous return. Other manifestations can include brown pigmentations and cellulitis.
A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy.
Which of the following findings should the nurse report to the provider?
A. Hypoactive bowel sounds
B. Indwelling urinary catheter output of 25 mL/hr
C. Heart rate of 96/min
D. Serous drainage at the surgical incision site - ANS-B. Indwelling urinary catheter output of 25
mL/hr
The nurse should report a urinary output of <30 mL/hr to the provider, as this can indicate
hypovolemia or renal complication.
A nurse is assessing a client who sustained superficial partial-thickness and deep
partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the
provider?
A. Edema in the burned extremities
B. Severe pain at the burn sites
C. Urine output of 30 mL/hr
D. Temperature of 39.1°C (102.4°F) - ANS-D. Temperature of 39.1°C (102.4°F)
An elevated temperature is an indication of infection, and the nurse should report this finding to
the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are
relatively pathogen-free. On approximately the third day following the injury, early colonization of
the wound surface by gram-negative organisms changes to predominantly gram-positive
opportunistic organisms.
