ATI ADULT MEDICAL SURGICAL NGN TEST
.A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed
RBC's. Which of
the following findings is an indication of a hemolytic transfusion reaction? Page 250 MS
ATI PDF 10.0
under acute hemolytic complications
A. Hypotension
B. Bradypnea-
C.Bradycardia
D.Hypothermia- - ✔✔A. Hypotension
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?
1. Heart rate 90/min
2. Absent bowel sounds → normal findings after major bowel surgery; takes several
days to return
to normal.
3. Hgb 8.2 g/dl
4. Gastric pH of 3.0 - ✔✔3. Hgb 8.2 g/dl
11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her
body which of
the following labs should the nurse expect during the first 24 hours
A. Decreased BUN ELEVATED DT fluid loss
B. Hypoglycemia
C. Hypoalbuminemia
D. Decreased Hematocrit - ✔✔C. Hypoalbuminemia (Low due to fluid loss)
21. A nurse is assessing the pain status of a group of clients. Which of the following
findings indicate a client is
experiencing referred pain? (page 30)
a A client who has angina reports substernal chest pain
b A client who has pancreatitis reports pain in the left shoulder - referred pain is pain
that is felt in
c A client who is postoperative reports incisional pain
d A client who has peritonitis reports generalized abdominal pain - ✔✔A client who has
pancreatitis reports pain in the left shoulder - referred pain is pain that is felt in
ANOTHER PLACE THAT IS NOT IN THE SAME AREA AS WHERE THE PAIN
SHOULD BE FELT.
22. A nurse is caring for a client who has just returned from surgery with an external
fixator to the left tibia. Which
,of the following assessments findings requires immediate intervention by the nurse? (p
.456 MS ATI PDF
10.0 chapter 71)
a The client reports a pain level of 7 on a scale from 0 -10 at the operative site.
b The clients capillary refill in the left toe is 6 seconds sxs of compartment syndrome.
ABCs are
compromised.
c The client has an oral temperature of 38.3 (100.9 F)
d The client has 100 ml of blood in the closed suction drained - ✔✔The clients capillary
refill in the left toe is 6 seconds sxs of compartment syndrome. ABCs are
compromised. (Cap refill should be below 3 seconds. This is sxs for compartment
syndrome.
Untreated can lead to necrosis.)
23. A nurse is assessing a client who has acute pancreatitis and has been receiving
total parenteral nutrition for the
past 72 hours. Which of the following findings requires the nurse to intervene? (chapter
47 page 299 MS ATI
PDF 10.0)
a Right upper quadrant pain
b Capillary blood glucose level of 164 mg/dl
c WBC count 13,000/mm3
d Crackle in bilateral lower lobes - ✔✔d Crackle in bilateral lower lobes (ABC's
compromised, also one of the complications of TPN is fluid
imbalance aka fluid volume excess.)
28.A nurse in an emergency department is assessing a client who has cirrhosis of the
liver. Which of the following is a
priority finding?
a.) Yellow sclera
b.) Mental confusion can lead to portal systemic encephalopathy
c.) Palmar erythema
d.) Spider angiomas - ✔✔b.) Mental confusion can lead to portal systemic
encephalopathy (page 358 MS ATI PDF 10.0 ::::::::::::::which
is something to report to provider meaning neuro is worsening)
29.A nurse is obtaining a medication history from a client who is to start therapy with
naproxen for
rheumatoid arthritis. Which of the following medications places the client at risk for
bleeding?
a.) Captopril
b.) Ibuprofen
c.) Digoxin
d.) Phenytoin - ✔✔b.) Ibuprofen
, 30.A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is
the priority
intervention by the nurse?
a.) Administer 0.9% sodium chloride
b.) Check potassium levels
c.) Initiate a continuous IV insulin infusion
d.) Begin bicarbonate continuous IV infusion - ✔✔c.) Initiate a continuous IV insulin
infusion
31.A nurse is assessing the extremities of a client who has Raynaud's disease. Which
of the following findings
should the nurse expect?
a.) Blanching of the hands
b.) Hyperactive reflexes
c.) Calf pain with foot dorsiflexion
d.) Vitiligo on affected extremities - ✔✔a.) Blanching of the hands (P 558 ati MD pdf
10.0)
33) A nurse is providing teaching to a client who has DVT. Which of the following
findings should the nurse
identify as a risk factor for the development of DVTs?
a. Hypertension
b. Cirrhosis
c. NSAIDS use
d. Oral Contraceptive Use - ✔✔d. Oral Contraceptive Use
34.A nurse is caring for client who has Cushing's disease. Which of the following actions
should the nurse take
first? (Click Exhibit button for additional information)
a. Check the client's medication administration record for antihypertensive medication.
b. Verify the client's understanding of sodium restriction.
c. Auscultate the client's lung sound
d. Determine the need for further glucose monitoring - ✔✔d. Determine the need for
further glucose monitoring
36.A nurse is assessing a client who has right-sided heart failure. Which of the following
assessment findings
should the nurse expect to find?
a. Oliguria (Left)
b. S3/S4 galloping heart sounds (Left)
c. Poor skin turgor
d. Pitting edema - ✔✔d. Pitting edema
37.A nurse is caring for a client who has newly inserted chest tube. The nurse should
clarify which of the
following prescriptions with the provider?
.A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed
RBC's. Which of
the following findings is an indication of a hemolytic transfusion reaction? Page 250 MS
ATI PDF 10.0
under acute hemolytic complications
A. Hypotension
B. Bradypnea-
C.Bradycardia
D.Hypothermia- - ✔✔A. Hypotension
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?
1. Heart rate 90/min
2. Absent bowel sounds → normal findings after major bowel surgery; takes several
days to return
to normal.
3. Hgb 8.2 g/dl
4. Gastric pH of 3.0 - ✔✔3. Hgb 8.2 g/dl
11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her
body which of
the following labs should the nurse expect during the first 24 hours
A. Decreased BUN ELEVATED DT fluid loss
B. Hypoglycemia
C. Hypoalbuminemia
D. Decreased Hematocrit - ✔✔C. Hypoalbuminemia (Low due to fluid loss)
21. A nurse is assessing the pain status of a group of clients. Which of the following
findings indicate a client is
experiencing referred pain? (page 30)
a A client who has angina reports substernal chest pain
b A client who has pancreatitis reports pain in the left shoulder - referred pain is pain
that is felt in
c A client who is postoperative reports incisional pain
d A client who has peritonitis reports generalized abdominal pain - ✔✔A client who has
pancreatitis reports pain in the left shoulder - referred pain is pain that is felt in
ANOTHER PLACE THAT IS NOT IN THE SAME AREA AS WHERE THE PAIN
SHOULD BE FELT.
22. A nurse is caring for a client who has just returned from surgery with an external
fixator to the left tibia. Which
,of the following assessments findings requires immediate intervention by the nurse? (p
.456 MS ATI PDF
10.0 chapter 71)
a The client reports a pain level of 7 on a scale from 0 -10 at the operative site.
b The clients capillary refill in the left toe is 6 seconds sxs of compartment syndrome.
ABCs are
compromised.
c The client has an oral temperature of 38.3 (100.9 F)
d The client has 100 ml of blood in the closed suction drained - ✔✔The clients capillary
refill in the left toe is 6 seconds sxs of compartment syndrome. ABCs are
compromised. (Cap refill should be below 3 seconds. This is sxs for compartment
syndrome.
Untreated can lead to necrosis.)
23. A nurse is assessing a client who has acute pancreatitis and has been receiving
total parenteral nutrition for the
past 72 hours. Which of the following findings requires the nurse to intervene? (chapter
47 page 299 MS ATI
PDF 10.0)
a Right upper quadrant pain
b Capillary blood glucose level of 164 mg/dl
c WBC count 13,000/mm3
d Crackle in bilateral lower lobes - ✔✔d Crackle in bilateral lower lobes (ABC's
compromised, also one of the complications of TPN is fluid
imbalance aka fluid volume excess.)
28.A nurse in an emergency department is assessing a client who has cirrhosis of the
liver. Which of the following is a
priority finding?
a.) Yellow sclera
b.) Mental confusion can lead to portal systemic encephalopathy
c.) Palmar erythema
d.) Spider angiomas - ✔✔b.) Mental confusion can lead to portal systemic
encephalopathy (page 358 MS ATI PDF 10.0 ::::::::::::::which
is something to report to provider meaning neuro is worsening)
29.A nurse is obtaining a medication history from a client who is to start therapy with
naproxen for
rheumatoid arthritis. Which of the following medications places the client at risk for
bleeding?
a.) Captopril
b.) Ibuprofen
c.) Digoxin
d.) Phenytoin - ✔✔b.) Ibuprofen
, 30.A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is
the priority
intervention by the nurse?
a.) Administer 0.9% sodium chloride
b.) Check potassium levels
c.) Initiate a continuous IV insulin infusion
d.) Begin bicarbonate continuous IV infusion - ✔✔c.) Initiate a continuous IV insulin
infusion
31.A nurse is assessing the extremities of a client who has Raynaud's disease. Which
of the following findings
should the nurse expect?
a.) Blanching of the hands
b.) Hyperactive reflexes
c.) Calf pain with foot dorsiflexion
d.) Vitiligo on affected extremities - ✔✔a.) Blanching of the hands (P 558 ati MD pdf
10.0)
33) A nurse is providing teaching to a client who has DVT. Which of the following
findings should the nurse
identify as a risk factor for the development of DVTs?
a. Hypertension
b. Cirrhosis
c. NSAIDS use
d. Oral Contraceptive Use - ✔✔d. Oral Contraceptive Use
34.A nurse is caring for client who has Cushing's disease. Which of the following actions
should the nurse take
first? (Click Exhibit button for additional information)
a. Check the client's medication administration record for antihypertensive medication.
b. Verify the client's understanding of sodium restriction.
c. Auscultate the client's lung sound
d. Determine the need for further glucose monitoring - ✔✔d. Determine the need for
further glucose monitoring
36.A nurse is assessing a client who has right-sided heart failure. Which of the following
assessment findings
should the nurse expect to find?
a. Oliguria (Left)
b. S3/S4 galloping heart sounds (Left)
c. Poor skin turgor
d. Pitting edema - ✔✔d. Pitting edema
37.A nurse is caring for a client who has newly inserted chest tube. The nurse should
clarify which of the
following prescriptions with the provider?
