NUR 250 MEDSURG 1 PROCTORED EXAM LATEST UPDATED 2025 ANSWERS WITH RATIONALE
• A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a
client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of
which of the following adverse effects? Old med surge docs we used
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take
on higher loads, you must taper it down to avoid hypoglycemia with lower
concentrations of
TPN
Abruptly discontinuing TPN will cause rebound hypoglycemia
• A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should
the nurse plan to take? P
. 250 chapter 40 pdf p . 678 lewis
a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older
adults
b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion- you get
vital signs at the initial first 15 to 30 minutes of the transfusion.
c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 .
d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249
• TOXIC SHOCK SYNDROME- same
• A nurse is providing discharge teaching to an older adult client who had an
exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler.
WHich of the following instructions should the nurse include? ( C) p . 132 ch 22
a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat inflammation.
b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters.
c. Obtain a yearly influenza immunization. - reduce risk of infection.
d. Assist use of pursed-lip breathing.- this is also one of the interventions the nurse
does but the question ask about fluticasone. It is a steroid, and we all know steroids
decresaes inflammation but also depress our immunue system. So getting a flu shot is
, priority.
• A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction
b. “Clean the incision daily with hydrogen peroxide.”- soap and water
c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs
with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip
greater than 90 degrees. NO crossing legs , no turing on operative side.
d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least
• Missing
• A nurse is caring for a client who is postoperative following a femur fracture. Which of the
following findings should the nurse report to the provider immediately?
a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71
b. The client has a temperature of 38.1 C (100.5F)
c. The clients incision is red and warm
d. The client reports incision pain
• A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the
following is an appropriate nursing action? P . 290 ch 46 pdf
a. Place the client in a protective environment
b. Obtain a stool specimen with gloves→ CONTACT ISO
c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub.
• A nurse is setting up a sterile field before performing a dressing change on client who is
postoperative. Which of the following actions should the nurse plan to take to maintain the
sterile field? (select all the apply)
a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder
is always non sterile so its ok to touch it .
b. Select a work surface at the nurses waist level- body mchiancis .
c. Apply sterile gloves before opening the pack- sterile package must be opened first before
donning sterile gloves
d. Open the first flap of the sterile package toward the nurse's body- must be AWAY
first , then sides , then TOWARDS the nurse .
, e. Place a surgical pack with a sterile drape on the work surface.
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect?
a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate .
b. Flushed skin- duskly it wIll look like
c. Frothy sputum-Left sided- can be blood tinged
d. Jugular vein
distention→ Right Rationale: ATI
MS: pg. 198 ch 32 pdf
Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria.
Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver
enlargement,
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal
pelvis. Identify the area where the nurse should expect the client to have referred pain. (
Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower
back
Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another
place other than where the pain should be felt.
• A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the
dialysate flow rate. Which of the following actions should the nurse take? (Select all the
apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf
a. monitor the access site for drainage.- to check for sxs of infection.
b. Strip the catheter tubing
c. Measure the amount of the dialysate outflow
d. Raise the client to high fowlers position- they must lie supine
e. Position the client to her other side.
• A nurse is planning to insert an indwelling catheter for a female client. Which of the following
actions should the nurse plan to take? Ati video tutorials foley
, a. Collect urine specimen from the drainage bag 1 hr after insertion
b. Raise the head of the bed to 45 degrees prior to insertion
c. Secure the catheter to the client's inner thigh
d. Attach the bag to the rail of the bed. –under non movable area
• A nurse is providing teaching for a client who has age-related macular degeneration which of
the following information should the nurse include in the teaching
a. A possible cause of this problem is long-term lack of dietary protein
b. You probably have a Detachment of your retina -vision is like having curtains over eyes
c. You probably have noticed a decline in your central vision
d. The doctor can perform surgery to correct the start paying the folds in your retina
Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular
degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure
, happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female,
HTN, diet lacking carotene.
• A nurse is preparing to discontinue long-term total parenteral nutrition (TPN) therapy for a
client for a client. The nurse should plan to discontinue the TPN gradually to reduce the risk of
which of the following adverse effects? Old med surge docs we used
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia (Repeat) Since your body is producing enough insulin to take
on higher loads, you must taper it down to avoid hypoglycemia with lower
concentrations of
TPN
Abruptly discontinuing TPN will cause rebound hypoglycemia
• A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should
the nurse plan to take? P
. 250 chapter 40 pdf p . 678 lewis
a. Administer the unit of packed RBC’s over 1 hr- 2- 4 hr its must be given for 2 -4 hours. older
adults
b. Obtain the client’s first set of vital signs 1 hr after initiating the transfusion- you get
vital signs at the initial first 15 to 30 minutes of the transfusion.
c. Initiate venous access with a 21-gauge needle - no more than 19, for a regular adult it is 18 or 20 .
d. Use Y tubing with 0.9% sodium chloride when administering the transfusion. Pg 249
• TOXIC SHOCK SYNDROME- same
• A nurse is providing discharge teaching to an older adult client who had an
exacerbation of COPD. The client is to start fluticasone by metered-dose inhaler.
WHich of the following instructions should the nurse include? ( C) p . 132 ch 22
a. Use fluticasone as needed for shortness of breath.- fluticasone used to treat inflammation.
b. Limit fluid intake to 1 L per day. - drink plenty to avoid dehydration. 2-3 liters.
c. Obtain a yearly influenza immunization. - reduce risk of infection.
d. Assist use of pursed-lip breathing.- this is also one of the interventions the nurse
does but the question ask about fluticasone. It is a steroid, and we all know steroids
decresaes inflammation but also depress our immunue system. So getting a flu shot is
, priority.
• A nurse is providing discharge teaching to an older adult client following a left total hip
arthroplasty. Which of the following instructions should the nurse include in the teaching?
a. “You can cross your legs at the ankles when sitting down.” -avoid flexion contraction
b. “Clean the incision daily with hydrogen peroxide.”- soap and water
c. “Install a raised toilet seat in your bathroom.” Pg 437 also use straight chairs
with arms, abduction pillow between the legs, avoid low chairs, and flexion of hip
greater than 90 degrees. NO crossing legs , no turing on operative side.
d. “You should use an incentive spirometer every 8 hrs.”- once every hour at least
• Missing
• A nurse is caring for a client who is postoperative following a femur fracture. Which of the
following findings should the nurse report to the provider immediately?
a. The client reports shortness of breath - embolism ABCS p . 457 chapter 71
b. The client has a temperature of 38.1 C (100.5F)
c. The clients incision is red and warm
d. The client reports incision pain
• A nurse is planning care for a client who Clostridium difficile gastroenteritis. Which of the
following is an appropriate nursing action? P . 290 ch 46 pdf
a. Place the client in a protective environment
b. Obtain a stool specimen with gloves→ CONTACT ISO
c. Clean surfaces with chlorhexidine-bleach D. Wash hands with alcohol-based hand rub.
• A nurse is setting up a sterile field before performing a dressing change on client who is
postoperative. Which of the following actions should the nurse plan to take to maintain the
sterile field? (select all the apply)
a. Grasp 2.5 cm (1 in ) of the outer edge to open the surgical wrap- 1 inch form broder
is always non sterile so its ok to touch it .
b. Select a work surface at the nurses waist level- body mchiancis .
c. Apply sterile gloves before opening the pack- sterile package must be opened first before
donning sterile gloves
d. Open the first flap of the sterile package toward the nurse's body- must be AWAY
first , then sides , then TOWARDS the nurse .
, e. Place a surgical pack with a sterile drape on the work surface.
1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect?
a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate .
b. Flushed skin- duskly it wIll look like
c. Frothy sputum-Left sided- can be blood tinged
d. Jugular vein
distention→ Right Rationale: ATI
MS: pg. 198 ch 32 pdf
Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria.
Right Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver
enlargement,
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal
pelvis. Identify the area where the nurse should expect the client to have referred pain. (
Find “hot spots” in the artwork) Pain travels downward to the inguinal area and lower
back
Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another
place other than where the pain should be felt.
• A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the
dialysate flow rate. Which of the following actions should the nurse take? (Select all the
apply?). Check answer i read pg 644-647 med surg it’s not so specific p. 370 ch 57 pdf
a. monitor the access site for drainage.- to check for sxs of infection.
b. Strip the catheter tubing
c. Measure the amount of the dialysate outflow
d. Raise the client to high fowlers position- they must lie supine
e. Position the client to her other side.
• A nurse is planning to insert an indwelling catheter for a female client. Which of the following
actions should the nurse plan to take? Ati video tutorials foley
, a. Collect urine specimen from the drainage bag 1 hr after insertion
b. Raise the head of the bed to 45 degrees prior to insertion
c. Secure the catheter to the client's inner thigh
d. Attach the bag to the rail of the bed. –under non movable area
• A nurse is providing teaching for a client who has age-related macular degeneration which of
the following information should the nurse include in the teaching
a. A possible cause of this problem is long-term lack of dietary protein
b. You probably have a Detachment of your retina -vision is like having curtains over eyes
c. You probably have noticed a decline in your central vision
d. The doctor can perform surgery to correct the start paying the folds in your retina
Rationale: ATI MS: PG. 63 Macular degeneration, often called age-related macular
degeneration (AMD), is the central loss of vision that affects the macula of the eye. NO cure
, happens alot in old people. Sxs: distorted vision, blurred vision, caused by smoking, female,
HTN, diet lacking carotene.
