ATI Proctored Med Surg
A nurse is teaching a client who asks about taking a glucosamine supplement for
osteoarthritis. Which of the following information should the nurse include in the teaching?
A. Avoid using glucosamine with chondroitin
B. Glucosamine can cause degradation of cartilage when used over a long time
C. Avoid taking glucosamine if you have a shellfish allergy
D. You can take glucosamine with an anticoagulant medication - ANSC
The medication is made from the exoskeletons of shellfish
A nurse is caring for a client who has visual loss. Which os the following actions should the
nurse implement?
A. Remove all objects from the client's bedside table
B. Instruct the client to open items in the food tray
C. Walk a step behind the client when assisting with ambulation
D. Count steps to the bathroom with the client - ANSD
Orient the client to the room to reduce the risk of falls
A nurse is discussing activity modification with a client who had a right total hip arthroplasty.
Which of the following statements should the nurse include in the information?
A. Plan to sit in a straight-backed chair when out of bed
B. Place a pillow between your legs when lying in bed
C. You can cross your legs at the ankles when sitting
D. You should bend at the waist when tying your shoes - ANSB
Prevent adduction of the hip and possible dislocation
A nurse is teaching a newly licensed nurse about preventing a catheter-associated urinary
tract infection for a client who has an indwelling urinary catheter. Which of the following
instructions should the nurse include?
A. Ensure the urinary catheter tubing is not kinked
B. Rest the catheter bag on the floor when the client is sitting in a chair
C. Clean the perineal area with an antiseptic solution
D. Empty the collection bag for the client every 12 hr - ANSA
Kinks can cause blockage of urinary flow and result in a UTI
A nurse is planning wound management for a client who has a stage 3 pressure injury.
Which of the following interventions should the nurse include in the plan?
A. Measure the depth of the wound with a cotton-tipped applicator
B. Measure the wound using a reusable tape measure
C. Cover the wound bed with dry gauze dressings
D. Cleanse the wound with soap and water - ANSA
Check wound for tunneling
A nurse is planning care for four clients following chase-of-shift report. Which of the following
clients is the nurse's priority?
,A. A client who had a stroke and has expressive aphasia
B. A client who has a hemoglobin of 11g/dL and requires 1 unit of blood
C. A client who has asthma and a peak expiratory flow rate in the green zone
D. A client who has peptic ulcer disease and a rigid abdomen - ANSD
The client is unstable and a rigid abdomen is a manifestation of a perforated peptic ulcer and
could lead to septicemia and shock.
A nurse is planning care for four clients following chase-of-shift report. Which of the following
clients should the nurse see first?
A. A client who is receiving propranolol and has a HR of 55/min
B. A client who is receiving warfarin and has an INR of 2.5
C. A client who has a pacemaker and has persistent hiccuping
D. A client who has cholecystitis and reports rebound tenderness - ANSC
Hiccuping is a manifestation of a dislocation of the pacemaker lead and could lead to
bradycardia and decreased CO
A nurse is reviewing the laboratory data of a client who is taking the herbal supplement
feverfew to reduce the frequency of migraine headaches. The nurse should identify that
which of the following findings indicates a potential contraindication to taking this herbal
supplement?
A. Potassium 3.5mEq/L
B. Platelet count 100,000/mm3
C.Cholesterol 250mg/dL
D. Urine bilirubin 0.2mg/dL - ANSB
Feverfew can lead to platelet dysfunction by suppressing platelet aggregation. A patient with
a decreased platelet count should not take fever few because it can increase the risk of
bleeding. Monitor for bleeding and impaired coagulation while taking feverfew
Ranges:
-Platelet 150,000-450,000/mm3
-Potassium 3.5-5mEq/L
-Cholesterol <200mg/dL
-Urine Bilirubin 0.0mg/dL
A nurse is caring for a client who is postoperative and has a history of heart failure. The
client reports slight dyspnea when ambulating. Which of the following findings should the
nurse expect when performing a skin assessment?
A. Petechiae over the client's chest and abdomen
B. Tenting of the skin on the client's arm
C. Shiny areas on the client's ankles and feet
D. Dry, flaky skin on the client's arms and hands - ANSC
Edema is an expected finding for HF with dyspnea with exertion. Edematous skin appears
taut and shiny, and can also look swollen and blanched.
A hospice nurse is planning end-of-life comfort care for a client. Which of the following
interventions should the nurse include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
, D. Remove visitors from the room if the Clint becomes restless - ANSC
Position laterally to improve breathing and promote comfort
A nurse is teaching a client who has a prescription for continuous ambulatory peritoneal
dialysis. Which of the following instructions should the nurse include?
A. Eat a low-fiber diet to maintain dialysate flow
B. Warm the dialysate in the microwave before instillation
C. Expect the dialysate outflow to appear cloudy
D. Allow the dialysate to dwell for 4 hr during each exchange - ANSD
Allow to dwell for 4-8 hr during each exchange to filter and remove fluid and waste products
A nurse is providing hydrotherapy for a client who has full-thickness turns on the lower leg.
Which of the following actions should the nurse take?
A. Perform the hydrotherapy three times per week
B. Wash the client's burns with mild soap
C. Rinse the client's burns with cold water
D. Immerse the client in a whirlpool tub - ANSB
Mild soap and water to clean and decried the wounds, promote healing, and reduce the risk
for infection
A nurse is assessing a client who is receiving head and neck radiation therapy to treat
esophageal cancer. The nurse should identify which of the following findings as an adverse
effect of this treatment?
A. The client has a productive cough
B. The client reports peripheral neuropathy
C. The client reports a dry mouth
D. The client reports diarrhea - ANSC
Dry mouth is an adverse effect of radiation therapy to the head and neck due to the damage
to the salivary glands. The client can develop tooth decay and difficulty swallowing. The
nurse should provide alcohol-free mouth rinse.
A nurse is assessing a client who has an endotracheal tube and is receiving mechanical
ventilation. The client is agitated and appears to be in respiratory distress. Which of the
following actions should the nurse take first?
A. Manually ventilate the client using a bag-valve device
B. Suction the client's endotracheal tube
C. Contact the respiratory therapist to check the client's ventilator
D. Obtain ABGs from the client - ANSA
Using ABC, the nurse should provide manual ventilation to reduce the risk for injury due to
hypoxia. Should disconnect the ventilator in case it is not functioning properly and provide
oxygenation until further assessment is obtained
A nurse is assisting with a paracentesis for a client who has ascites. Which of the following
actions should the nurse take?
A. Place the client's peritoneal fluid specimen in the refrigerator following the procedure
B. Position the client into a left lateral position for the procedure
C. Weigh the client before the procedure
D. Instruct the client to have a full bladder during the procedure - ANSC
A nurse is teaching a client who asks about taking a glucosamine supplement for
osteoarthritis. Which of the following information should the nurse include in the teaching?
A. Avoid using glucosamine with chondroitin
B. Glucosamine can cause degradation of cartilage when used over a long time
C. Avoid taking glucosamine if you have a shellfish allergy
D. You can take glucosamine with an anticoagulant medication - ANSC
The medication is made from the exoskeletons of shellfish
A nurse is caring for a client who has visual loss. Which os the following actions should the
nurse implement?
A. Remove all objects from the client's bedside table
B. Instruct the client to open items in the food tray
C. Walk a step behind the client when assisting with ambulation
D. Count steps to the bathroom with the client - ANSD
Orient the client to the room to reduce the risk of falls
A nurse is discussing activity modification with a client who had a right total hip arthroplasty.
Which of the following statements should the nurse include in the information?
A. Plan to sit in a straight-backed chair when out of bed
B. Place a pillow between your legs when lying in bed
C. You can cross your legs at the ankles when sitting
D. You should bend at the waist when tying your shoes - ANSB
Prevent adduction of the hip and possible dislocation
A nurse is teaching a newly licensed nurse about preventing a catheter-associated urinary
tract infection for a client who has an indwelling urinary catheter. Which of the following
instructions should the nurse include?
A. Ensure the urinary catheter tubing is not kinked
B. Rest the catheter bag on the floor when the client is sitting in a chair
C. Clean the perineal area with an antiseptic solution
D. Empty the collection bag for the client every 12 hr - ANSA
Kinks can cause blockage of urinary flow and result in a UTI
A nurse is planning wound management for a client who has a stage 3 pressure injury.
Which of the following interventions should the nurse include in the plan?
A. Measure the depth of the wound with a cotton-tipped applicator
B. Measure the wound using a reusable tape measure
C. Cover the wound bed with dry gauze dressings
D. Cleanse the wound with soap and water - ANSA
Check wound for tunneling
A nurse is planning care for four clients following chase-of-shift report. Which of the following
clients is the nurse's priority?
,A. A client who had a stroke and has expressive aphasia
B. A client who has a hemoglobin of 11g/dL and requires 1 unit of blood
C. A client who has asthma and a peak expiratory flow rate in the green zone
D. A client who has peptic ulcer disease and a rigid abdomen - ANSD
The client is unstable and a rigid abdomen is a manifestation of a perforated peptic ulcer and
could lead to septicemia and shock.
A nurse is planning care for four clients following chase-of-shift report. Which of the following
clients should the nurse see first?
A. A client who is receiving propranolol and has a HR of 55/min
B. A client who is receiving warfarin and has an INR of 2.5
C. A client who has a pacemaker and has persistent hiccuping
D. A client who has cholecystitis and reports rebound tenderness - ANSC
Hiccuping is a manifestation of a dislocation of the pacemaker lead and could lead to
bradycardia and decreased CO
A nurse is reviewing the laboratory data of a client who is taking the herbal supplement
feverfew to reduce the frequency of migraine headaches. The nurse should identify that
which of the following findings indicates a potential contraindication to taking this herbal
supplement?
A. Potassium 3.5mEq/L
B. Platelet count 100,000/mm3
C.Cholesterol 250mg/dL
D. Urine bilirubin 0.2mg/dL - ANSB
Feverfew can lead to platelet dysfunction by suppressing platelet aggregation. A patient with
a decreased platelet count should not take fever few because it can increase the risk of
bleeding. Monitor for bleeding and impaired coagulation while taking feverfew
Ranges:
-Platelet 150,000-450,000/mm3
-Potassium 3.5-5mEq/L
-Cholesterol <200mg/dL
-Urine Bilirubin 0.0mg/dL
A nurse is caring for a client who is postoperative and has a history of heart failure. The
client reports slight dyspnea when ambulating. Which of the following findings should the
nurse expect when performing a skin assessment?
A. Petechiae over the client's chest and abdomen
B. Tenting of the skin on the client's arm
C. Shiny areas on the client's ankles and feet
D. Dry, flaky skin on the client's arms and hands - ANSC
Edema is an expected finding for HF with dyspnea with exertion. Edematous skin appears
taut and shiny, and can also look swollen and blanched.
A hospice nurse is planning end-of-life comfort care for a client. Which of the following
interventions should the nurse include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
, D. Remove visitors from the room if the Clint becomes restless - ANSC
Position laterally to improve breathing and promote comfort
A nurse is teaching a client who has a prescription for continuous ambulatory peritoneal
dialysis. Which of the following instructions should the nurse include?
A. Eat a low-fiber diet to maintain dialysate flow
B. Warm the dialysate in the microwave before instillation
C. Expect the dialysate outflow to appear cloudy
D. Allow the dialysate to dwell for 4 hr during each exchange - ANSD
Allow to dwell for 4-8 hr during each exchange to filter and remove fluid and waste products
A nurse is providing hydrotherapy for a client who has full-thickness turns on the lower leg.
Which of the following actions should the nurse take?
A. Perform the hydrotherapy three times per week
B. Wash the client's burns with mild soap
C. Rinse the client's burns with cold water
D. Immerse the client in a whirlpool tub - ANSB
Mild soap and water to clean and decried the wounds, promote healing, and reduce the risk
for infection
A nurse is assessing a client who is receiving head and neck radiation therapy to treat
esophageal cancer. The nurse should identify which of the following findings as an adverse
effect of this treatment?
A. The client has a productive cough
B. The client reports peripheral neuropathy
C. The client reports a dry mouth
D. The client reports diarrhea - ANSC
Dry mouth is an adverse effect of radiation therapy to the head and neck due to the damage
to the salivary glands. The client can develop tooth decay and difficulty swallowing. The
nurse should provide alcohol-free mouth rinse.
A nurse is assessing a client who has an endotracheal tube and is receiving mechanical
ventilation. The client is agitated and appears to be in respiratory distress. Which of the
following actions should the nurse take first?
A. Manually ventilate the client using a bag-valve device
B. Suction the client's endotracheal tube
C. Contact the respiratory therapist to check the client's ventilator
D. Obtain ABGs from the client - ANSA
Using ABC, the nurse should provide manual ventilation to reduce the risk for injury due to
hypoxia. Should disconnect the ventilator in case it is not functioning properly and provide
oxygenation until further assessment is obtained
A nurse is assisting with a paracentesis for a client who has ascites. Which of the following
actions should the nurse take?
A. Place the client's peritoneal fluid specimen in the refrigerator following the procedure
B. Position the client into a left lateral position for the procedure
C. Weigh the client before the procedure
D. Instruct the client to have a full bladder during the procedure - ANSC
