ATI Med-Surg Proctored Exam. 62 Questions and Correct answers.

ATI Med-Surg Proctored Exam. 62 Questions and Correct answers. 1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3. - Correct answer c. Hgb 8.2 g/dl Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging." 2. "A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonat - Correct answer a. Desmopressin Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase ADH and to stop patient on urinating." 3. "A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood - GI bleed c. Urine for white blood cells d. Serum calcium Rationale: - Correct answer b. Stool for occult blood - GI bleed Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abdominal pain)" 4. "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. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansetron. - Correct answer Initiate airborne precautions" 5. "A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN - Correct answer C The nurse should instruct the patient to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space." 6. "A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side lying position C. Provide privacy D. Lower the client to the floor - Correct answer D" 7. "A nurse is teaching a client how to perform a breast self exam. The nurse should identify which of the following findings as an indication of breast cancer? A. Lumps that are mobile and tender upon palpation prior to period B. Multiple round masses that are tender and found in both breasts C. Bilaterally darkened areolas D. A nontender, hard lump that is palpated in one breast - Correct answer D" 8. "A nurse is preparing to change the bed linens of a client who has AIDS and is continent of stool Which of the following PPE should the nurse don prior to providing client care (SATA)? A. Gown B. Gloves C. Mask D. Hair cover E. Goggles - Correct answer A B" 9. "A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss? – Correct answer Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.)" 10. "A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching? Correct answer This type of insulin should be given at the same time everyday. (It is released over a 24hr period)" 11. "A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions? - Correct answer "I don't cross my legs anymore"." 12. "A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors? - Correct answer Visitors must don a gown & gloves prior to entering the client's room." 13. "A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider? - Correct answer Onset of nausea" 14. "A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client? - Correct answer Rephrase client instructions when not understood." 15. "A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication? - Correct answer Pulmonary Embolism" 16. "A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal? - Correct answer Lack of sensation between the first and second toes" 17. "A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching? - Correct answer Limit contact with large groups of people" 18. "A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications? - Correct answer Encourage the client to use an incentive spirometer every hour while awake" 19. "A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia? - Correct answer Bradycardia" 20. "A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first? - Correct answer Initiate oxygen at 4 L/min via nasal cannula" 21. "A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." What response should the nurse make? - Correct answer "Tell me more about the way you are feeling."" 22. "A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority? - Correct answer Dysrhythmia" 23. "A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown? - Correct answer Keep the skin dry and free of perspiration" 24. "A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take? - Correct answer Have a designated stethoscope in the client's room" 25. "A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first? - Correct answer Stop the infusion" 26. "A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as what? - Correct answer Hyperactive bowel sounds" 27. "A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication? - Correct answer Decreased potassium" 28. "A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching? - Correct answer Apply cold packs to the joints" 29. "A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect? - Correct answer Bradycardia" 30. "A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching? - Correct answer Take the calcium supplements with meals" 31. "A nurse is reviewing the medical record for an older adult client who is experiencing nausea & vomiting. Based on the client data, what action should the nurse take? (Na 142 mEq, K+ 4.2 mEq/L, BUN 36 mg/dL, Creatinine 1.4 mg/dL) - Correct answer Notify the charge nurse of the client's BUN level" 32. "A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first? - Correct answer Institute airborne precautions" 33. "A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. What action should the nurse take? - Correct answer Blow cool air into the cast using a blow dryer on a cool setting" 34. "A nurse is planning care for a group of clients after receiving change-of-shift report. What client should the nurse see first? - Correct answer A client who is dehydrated, has mental confusion, & was found getting out of bed several times during the night." 35. "A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take? - Correct answer Administer oxygen via nasal cannula" 36. "A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take? - Correct answer Withhold the dose" 37. "A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first? - Correct answer Check for kinks in the NG tube" 38. "A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. What instructions should the nurse include in the teaching? - Correct answer Maintain hip flex ion to 90 or less when sitting" 39. "A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse? - Correct answer Oxygen saturation of 88%" 40. "A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome? - Correct answer Place the client in the supine position after meals" 41. "A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. What instructions should the nurse include? - Correct answer Drink beverages at the end of meals" 42. "A nurse is reinforcing teaching with a client who has chronic kidney disease about management. What statement by the client indicates an understanding of the teaching? - Correct answer I will limit my daily intake of protein" 43. "A nurse is caring for a client who has dementia due to Alzheimer's disease. What action should the nurse take to reduce the client's confusion? - Correct answer Encourage reminiscence of past experiences" 44. "A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. What information should the nurse include in the teaching? - Correct answer The virus can be transmitted without lesions present" 45. "A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. What instruction should the nurse include in the teaching? - Correct answer Add oily fish to your diet" 46. "A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. What instructions on preparing the insulin should the nurse include? - Correct answer Withdraw the regular insulin before withdrawing the NPH insulin" 47. "A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. What instructions should the nurse include to promote comfort? - Correct answer Sleep on a firm mattress" 48. "A nurse is assisting in the plan of care for a client who has a recent left hemispheric stroke. What action should the nurse include in the plan? - Correct answer Use simple verbal cues when directing tasks" 49. "A nurse is reinforcing teaching with a client who is taking Levothyroxine. What statement by the client indicates an understanding of the teaching? - Correct answer The medication should be taken before I eat breakfast every morning" 50. "A nurse is reviewing medical record of a client who is postoperative. What finding should the nurse identify as a complication of surgery? - Correct answer WBC count of 15,000/ mmm3" 51. "A nurse is reviewing the medication administration record of a client who has osteoarthritis. What analgesic prescription should the the nurse expect to administer when the client reports pain? - Correct answer Acetaminophen" 52. "A nurse is assisting with an educational program for clients who have newly diagnosed with diabetes mellitus. What instruction should the nurse include in the program regarding insulin? - Correct answer Opened insulin can be stored on a cool countertop away from light" 53. "A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from PACU following a right total knee arthroplasty. What interventions should the nurse include in the plan? - Correct answer Assist the client to change position every 2hr" 54. "A nurse is reinforcing teaching with a client who has circulatory comprise in the lower extremities due to peripheral vascular disease. What action should the nurse take? - Correct answer Educate the client about choosing low-fat, low cholesterol foods" 55. "A nurse is caring for a client who is post operative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. What prescription should the nurse expect the provider to order? - Correct answer Irrigate the urethral catheter with 0.9% sodium chloride" 56. "A nurse is caring for a client who has a new cast on her left forearm and report severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. What fracture complication should the nurse suspect? - Correct answer Compartment syndrome" 57. "A nurse is reviewing the plan of care for an older adult client who is 1 day post operative following a total hip arthroplasty. What interventions should the nurse contribute to the plan of care? - Correct answer Keep an abduction pillow between the client's legs" 58. "A nurse is caring for four clients. What conditions should the nurse identify as a risk for developing vascular disease? - Correct answer Diabetes mellitus" 59. "A nurse is caring for a female client who is being treated for dehydration due to nausea & vomiting. What finding should the nurse report to the provider? - Correct answer Heart rate 120/ min" 60. "A nurse is reinforcing teaching to a client about preventing osteoporosis. What statement indicates an understanding of the teaching? - Correct answer I will limit my coffee intake" 61. "A nurse is contributing to the plan of care for a client who has tuberculosis (TB). What intervention should the nurse include? - Correct answer Place the client in a negative pressure airflow room" 62. "A nurse is contributing to the plan of care for a client who has pericarditis. What position should the nurse plan to place the client to decrease plan? - Correct answer Upright, leaning forward"