ATI MED SURG PROCTORED PRACTICE
B
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which
of the following instructions should the nurse include in the teaching?
1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water. - 1
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway.. - 1
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and
reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse
take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet. - 2
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the
provider?
,1) Emesis of 100 mL
2) Oral temperature of 37.5Æ C (99.5Æ F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale - 3
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription
for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects
of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia - 1
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones." - 4
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is
postoperative. After calling for assistance, which of the following actions should the nurse take
first?
1) Cover the client's wound with a moist, sterile dressing.
2) Have the client lie supine with knees flexed.
3) Check the client's vital signs.
4) Inform the client about the need to return to surgery. - 1
A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic
acidosis. Which of the following manifestations should the nurse expect?
,1) Cool, clammy skin.
2) Hyperventilation
3) Increased blood pressure
4) Bradycardia - 2
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of
the following should the nurse include in the teaching?
1) Avoid bending at the waist.
2) Remove the eye shield at bedtime.
3) Limit the use of laxatives if constipated.
4) Seeing flashes of light is an expected finding following extraction. - 1
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client
refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic. - 3
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse
suspects the client's wound is infected because the drainage from the dressing is yellow and
thick. Which of the following findings should the nurse report as the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent - 4
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent
postoperative complications which of the following actions should be reinforced during the
teaching?
, 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed position.
3) bPlace bthe bclient binto ba bhigh bFowler's bposition bwhen binitiating bthe bCPM bexercises.
4) bAlign bthe bjoints bof bthe bCPM bmachine bwith bthe bknee bgatch bin bthe bclient's bbed. b- b1
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas bemphysema. bWhich bof bthe bfollowing bfindings
bshould bthe bnurse bexpect? b(Select ball bthat bapply.)
1) bDyspnea
2) bBarrel bchest
3) bClubbing bof bthe bfingers
4) bShallow brespirations
5) bBradycardia b- b1 b2 b3 b4
A bnurse bis bcaring bfor ba bclient bwho bsustained ba bbasal bskull bfracture. bWhen bperforming bmorning
bhygiene bcare, bthe bnurse bnotices ba bthin bstream bof bclear bdrainage bcoming bfrom bout bof bthe bclient's
bright bnostril. bWhich bof bthe bfollowing bactions bshould bthe bnurse btake bfirst?
1) bTake bthe bclient's btemperature.
2) bPlace ba bdressing bunder bthe bclient's bnose.
3) bNotify bthe bcharge bnurse.
4) bTest bthe bdrainage bfor bglucose. b- b4
A bnurse bis bcaring bfor ba bclient bwho bhas ba bspinal bcord binjury bat bT-4. bThe bnurse bshould brecognize
bthat bthe bclient bis bat brisk bfor bautonomic bdysreflexia. bWhich bof bthe bfollowing binterventions bshould
bthe
nurse btake bto bprevent bautonomic bdysreflexia?
1) bMonitor bfor belevated bblood bpressure.
2) bProvide banalgesia bfor bheadaches.
3) bPrevent bbladder bdistention.
B
A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which
of the following instructions should the nurse include in the teaching?
1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water. - 1
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway.. - 1
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and
reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse
take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet. - 2
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the
provider?
,1) Emesis of 100 mL
2) Oral temperature of 37.5Æ C (99.5Æ F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale - 3
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription
for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects
of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia - 1
A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones." - 4
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is
postoperative. After calling for assistance, which of the following actions should the nurse take
first?
1) Cover the client's wound with a moist, sterile dressing.
2) Have the client lie supine with knees flexed.
3) Check the client's vital signs.
4) Inform the client about the need to return to surgery. - 1
A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic
acidosis. Which of the following manifestations should the nurse expect?
,1) Cool, clammy skin.
2) Hyperventilation
3) Increased blood pressure
4) Bradycardia - 2
A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of
the following should the nurse include in the teaching?
1) Avoid bending at the waist.
2) Remove the eye shield at bedtime.
3) Limit the use of laxatives if constipated.
4) Seeing flashes of light is an expected finding following extraction. - 1
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client
refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic. - 3
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse
suspects the client's wound is infected because the drainage from the dressing is yellow and
thick. Which of the following findings should the nurse report as the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent - 4
A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent
postoperative complications which of the following actions should be reinforced during the
teaching?
, 1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed position.
3) bPlace bthe bclient binto ba bhigh bFowler's bposition bwhen binitiating bthe bCPM bexercises.
4) bAlign bthe bjoints bof bthe bCPM bmachine bwith bthe bknee bgatch bin bthe bclient's bbed. b- b1
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas bemphysema. bWhich bof bthe bfollowing bfindings
bshould bthe bnurse bexpect? b(Select ball bthat bapply.)
1) bDyspnea
2) bBarrel bchest
3) bClubbing bof bthe bfingers
4) bShallow brespirations
5) bBradycardia b- b1 b2 b3 b4
A bnurse bis bcaring bfor ba bclient bwho bsustained ba bbasal bskull bfracture. bWhen bperforming bmorning
bhygiene bcare, bthe bnurse bnotices ba bthin bstream bof bclear bdrainage bcoming bfrom bout bof bthe bclient's
bright bnostril. bWhich bof bthe bfollowing bactions bshould bthe bnurse btake bfirst?
1) bTake bthe bclient's btemperature.
2) bPlace ba bdressing bunder bthe bclient's bnose.
3) bNotify bthe bcharge bnurse.
4) bTest bthe bdrainage bfor bglucose. b- b4
A bnurse bis bcaring bfor ba bclient bwho bhas ba bspinal bcord binjury bat bT-4. bThe bnurse bshould brecognize
bthat bthe bclient bis bat brisk bfor bautonomic bdysreflexia. bWhich bof bthe bfollowing binterventions bshould
bthe
nurse btake bto bprevent bautonomic bdysreflexia?
1) bMonitor bfor belevated bblood bpressure.
2) bProvide banalgesia bfor bheadaches.
3) bPrevent bbladder bdistention.
