FORM A, B & C ACTUAL EXAM EACH FORM
CONTAINS 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
|ALREADY GRADED A+
, ATI RN ADULT MEDICAL SURGICAL 2023 FOR NGN FORM A, B & C ACTUAL EXAM EACH
FORM CONTAINS 100 QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
|ALREADY GRADED A+
FORM A
A nurse in an acute care facility is caring for a client who is at risk for seizures.Which of
the following precautions should the nurse implement? - ANSWER- Ensure the client has
a patient IV.
RATIONALE: The nurse should ensure the client has IV access in the event that
the client requires medication to stop seizure activity.
A nurse is caring for a client who is postoperative following a total hip arthroplasty.
Which of the following laboratory values should the nurse report tothe provider? -
ANSWER- Hgb 8 g/dL
RATIONALE: The nurse should report an Hgb level of 8 g/dL, which is below
the expected reference range and is an indicator of postoperative hemorrhage oranemia.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr
ago. Which of the following findings should the nurse expect? -ANSWER- Stone fragments
in the urine
RATIONALE: ESWL is an effort to break the calculi so that the fragments passdown the ureter,
into the bladder, and through the urethra during voiding.
Following the procedure, the nurse should strain the client's urine to confirm thepassage
of stones.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, anda productive
cough. Which of the following actions should the nurse take first? - ANSWER- Initiate airborne
precautions.
RATIONALE: This client is exhibiting manifestations of tuberculosis. The
greatest risk in this client situation is for other people in the facility to acquire an airborne
disease from this client. Therefore, the first action the nurse should take isto initiate airborne
precautions.
,A nurse is caring for a client who is receiving total parenteral nutrition
(TPN). Anew bag is not available when the current infusion is nearly completed. Which
ofthe following actions should the nurse take? - ANSWER- Administer dextrose 10% in
water until the new bag arrives.
RATIONALE: TPN solutions have a high concentration of dextrose.
Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose
10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.
A nurse is providing teaching to a client who has hypothyroidism and is receivinglevothyroxine.
The nurse should instruct the client that which of the following supplements can interfere with
the effectiveness of the medication? - ANSWER- Calcium
RATIONALE: Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can interfere withthe
metabolism of a number of medications, including levothyroxine. The nurse should instruct the
client to avoid taking calcium within 4 hr of levothyroxine administration.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The
client appears anxious and restless, and the high-pressure alarm issounding. Which of the
following actions should the nurse take first? - ANSWER-Instruct the client to allow the
machine to breathe for them.
RATIONALE: When providing client care, the nurse should first use the least
restrictive intervention. Therefore, the first action the nurse should take is to provide verbal
instructions and emotional support to help the client relax and allowthe ventilator to work.
Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."
A nurse is caring for a client who has a prescription for enalapril. The nurse shouldidentify
which of the following findings as an adverse effect of the medication? - ANSWER- Orthostatic
hypotension
RATIONALE: The nurse should identify that dilation of arteries and veins causes
orthostatic hypotension, which is an adverse effect of enalapril.
, A nurse is caring for a client who has a stage III pressure injury.
Which of the following findings contributes to delayed wound healing?
- ANSWER- Urineoutput 25 mL/hr
RATIONALE: Urinary output reflects fluid status. Inadequate urine output can
indicate dehydration, which can delay wound healing.
A nurse is providing teaching to an older adult client who has cancer and a new prescription
for an opioid analgesic for pain management. Which of the followinginformation should the
nurse include in the teaching? - ANSWER- "You should void every 4 hours to decrease the risk
of urinary retention."
RATIONALE: The nurse should instruct the client to void at least every 4 hr to
decrease the risk of urinary retention, which is an adverse effect of opioidanalgesics.
A nurse is caring for a client who has portal hypertension. The client is vomitingblood mixed with
food after a meal. Which of the following actions should the nurse take first? - ANSWER- Obtain
vital signs.
RATIONALE: The first action the nurse should take using the nursing process is
to assess the client's vital signs. A client who has portal hypertension can develop esophageal
varices, which are fragile and can rupture, resulting in large amounts ofblood loss and shock.
Obtaining vital signs provides information about the client's condition that can contribute to
decision making.
A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a
gastrectomyA nurse is providing teaching for the client. Which of thefollowing instructions
should the nurse include? - ANSWER- Avoid drinking fluids with meals
Eat several small meals per
dayConsume high-protein snacks
Avoid highly seasoned foods
RATIONALE: Maintain a high carbohydrate intake is incorrect. Dumping
syndrome requires a low carbohydrate diet because of reactive hypoglycemia.