NGN ATI PN ADULT MEDICAL SURGICAL
PROCTORED EXAM
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and
vomiting for 2 days. Which of the following laboratory values should the nurse report
to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L - ANSWER D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can
lead to lithium accumulation and places the client at risk for lithium toxicity. The
nurse should report this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3.
Which of the following
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. - ANSWER A. Cleanse
the client's toothbrush with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low
WBC count can be caused by cancer or cancer treatment. The nurse should instruct
the client to cleanse their toothbrush with hydrogen peroxide. People with leukemia
or leukopenia should avoid using disposable razors, which can cause cuts and
bleeding that can lead to infections. Instead, they recommend using an electric razor
to reduce the risk of injury. Encouraging the client to eat unpasteurized dairy
products is not recommended as they can contain harmful bacteria that can cause
infections. Decreasing the client's protein intake is not recommended as protein is
important for wound healing and immune function
TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of
the following actions should the nurse take first?
a) Activate the fire alarm system.
,b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - ANSWER C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due
to chronic arthritis. Which of the following interventions should the nurse include in
the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. - ANSWER A. Apply foam
handles to the client's eating utensils.
Rationale:
To help a client with chronic arthritis who experiences difficulty eating, applying foam
handles to the eating utensils can provide a larger, more comfortable grip and
reduce strain on the joints. Asking for a puree diet may not be necessary unless
swallowing difficulties are present. Having an assistive personnel feed the client may
not promote independence. While obtaining a referral for physical therapy may be
beneficial for overall mobility, it does not directly address the client's difficulty with
eating.
A nurse is providing directions to an assistive personnel about moving a client up in
bed.
a. "Place a pillow under the client's head prior to repositioning."
b. "Keep your feet close together while moving the client"
c "Face in the direction of the client's movement"
d. "Move the client's arms to his sides prior to repositioning." - ANSWER C. "Face in
the direction of the client's movement."
Rational:
When moving a client up in bed, it is important for the nurse to face in the direction of
the client's movement to maintain proper body mechanics and ensure safe transfer.
1)Adjust the head of the bed to a flat position.
,2)Remove all pillows from under the client.
3)Position the UAP on the side opposite the nurse.
4)Place a friction-reducing sheet under the client.
5)Ask the client to bend the legs and place the chin on the chest.
6)Grasp the sheet and move the client on the count of three.
A nurse is obtaining a medication history from a client who is to start taking
nitroglycerin for chest discomfort with activity. Which of the following medications
should the nurse instruct the client to avoid taking within 24 hrs of using
nitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole - ANSWER C. Sildenafil
Rationale:
Sildenafil treats PAH (pulmonary arterial hypertension) by relaxing the blood vessels
in the lungs to allow blood to flow easily.
Same as, nitroglycerin is a vaso-dilator which is primarily to treat anginal chest pain
and thereby it reduces blood pressure.
Remaining drugs like omeprazole and atorvastatin can be given for patients with in
24hrs of nitroglycerin administration.
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse
should monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever - ANSWER Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and
causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who
has diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. - ANSWER D. Hold the client's
finger in a dependent
position.
Rationale:
, The nurse should clean the client's finger with an alcohol swab and prick the side of
the finger, not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol
could cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause
tissue damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of
the following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." - ANSWER A. "It is common for
one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the
right.
This is because of the difference in the percentage of breast tissues and fatty
tissues, that's why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be
taken regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period
starts." The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive
age usually after a week when the period starts and at the same day of every month
for women who have attained menopause.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
following statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around
the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma." - ANSWER C. "I will use a skin sealant before I apply
the
bag."
Rationale:
PROCTORED EXAM
TEST
A nurse is caring for a client who is taking lithium and reports persistent nausea and
vomiting for 2 days. Which of the following laboratory values should the nurse report
to the provider?
a) Potassium 4.0 mEq/L
b) Lithium 0.9 mEq/L
c) BUN 12 mg/dL
d) Sodium 132 mEq/L - ANSWER D. Sodium 132 mEq/L
Rationale:
The nurse should identify that a sodium level of 132 mEq/L is not within the expected
reference range of 136 to 145 mEq/L. This finding indicates hyponatremia, which can
lead to lithium accumulation and places the client at risk for lithium toxicity. The
nurse should report this finding to the provider.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3.
Which of the following
actions should the nurse take?
a) Cleanse the client's toothbrush with hydrogen peroxide.
b) Instruct the client to use a disposable razor to shave.
c) Decrease the client's protein intake.
d) Encourage the client to eat unpasteurized dairy products. - ANSWER A. Cleanse
the client's toothbrush with hydrogen peroxide.
Rationale:
A WBC count of 4,000/mm3 is considered low and is known as leukopenia. A low
WBC count can be caused by cancer or cancer treatment. The nurse should instruct
the client to cleanse their toothbrush with hydrogen peroxide. People with leukemia
or leukopenia should avoid using disposable razors, which can cause cuts and
bleeding that can lead to infections. Instead, they recommend using an electric razor
to reduce the risk of injury. Encouraging the client to eat unpasteurized dairy
products is not recommended as they can contain harmful bacteria that can cause
infections. Decreasing the client's protein intake is not recommended as protein is
important for wound healing and immune function
TEST
A nurse enters a client's room and sees smoke coming from the bathroom. Which of
the following actions should the nurse take first?
a) Activate the fire alarm system.
,b) Use a fire extinguisher at the source of the
smoke.
c) Assist the client to a nearby common area.
d) Close the doors to the room and to the
bathroom. - ANSWER C. Assist the client to a nearby common area.
Rationale:
use
Rescue
Alarm
Contain
Extinguish
TEST
A nurse is contributing to the plan of care for a client who reports difficulty eating due
to chronic arthritis. Which of the following interventions should the nurse include in
the plan?
a) Apply foam handles to the client's eating utensils.
b) Obtain a referral for physical therapy.
c) Have an assistive personnel feed the client.
d) Ask the provider for a prescription for a pureed diet. - ANSWER A. Apply foam
handles to the client's eating utensils.
Rationale:
To help a client with chronic arthritis who experiences difficulty eating, applying foam
handles to the eating utensils can provide a larger, more comfortable grip and
reduce strain on the joints. Asking for a puree diet may not be necessary unless
swallowing difficulties are present. Having an assistive personnel feed the client may
not promote independence. While obtaining a referral for physical therapy may be
beneficial for overall mobility, it does not directly address the client's difficulty with
eating.
A nurse is providing directions to an assistive personnel about moving a client up in
bed.
a. "Place a pillow under the client's head prior to repositioning."
b. "Keep your feet close together while moving the client"
c "Face in the direction of the client's movement"
d. "Move the client's arms to his sides prior to repositioning." - ANSWER C. "Face in
the direction of the client's movement."
Rational:
When moving a client up in bed, it is important for the nurse to face in the direction of
the client's movement to maintain proper body mechanics and ensure safe transfer.
1)Adjust the head of the bed to a flat position.
,2)Remove all pillows from under the client.
3)Position the UAP on the side opposite the nurse.
4)Place a friction-reducing sheet under the client.
5)Ask the client to bend the legs and place the chin on the chest.
6)Grasp the sheet and move the client on the count of three.
A nurse is obtaining a medication history from a client who is to start taking
nitroglycerin for chest discomfort with activity. Which of the following medications
should the nurse instruct the client to avoid taking within 24 hrs of using
nitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole - ANSWER C. Sildenafil
Rationale:
Sildenafil treats PAH (pulmonary arterial hypertension) by relaxing the blood vessels
in the lungs to allow blood to flow easily.
Same as, nitroglycerin is a vaso-dilator which is primarily to treat anginal chest pain
and thereby it reduces blood pressure.
Remaining drugs like omeprazole and atorvastatin can be given for patients with in
24hrs of nitroglycerin administration.
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse
should monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever - ANSWER Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and
causing flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who
has diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. - ANSWER D. Hold the client's
finger in a dependent
position.
Rationale:
, The nurse should clean the client's finger with an alcohol swab and prick the side of
the finger, not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol
could cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause
tissue damage.
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of
the following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." - ANSWER A. "It is common for
one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the
right.
This is because of the difference in the percentage of breast tissues and fatty
tissues, that's why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be
taken regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period
starts." The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive
age usually after a week when the period starts and at the same day of every month
for women who have attained menopause.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
following statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around
the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma." - ANSWER C. "I will use a skin sealant before I apply
the
bag."
Rationale:
