ATI Medical Surgical Assessment B
verified with correct question and
answers
1. The nurse requests the client to sign a surgical informed consent form for an
emergency appendectomy. Which statement by the client indicates further teaching
is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - 1. "I will be glad when this is
over so I can go home today."
2. The nurse in the holding area of the surgery department is interviewing a client
who requests to keep his religious medal on during surgery. Which intervention
should the nurse implement?
1. Notify the surgeon about the client's request to wear the medal
2. Tape the medal to the client and allow the client to wear the medal
3. Request the family member take the medal prior to surgery
4. Explain taking the medal to surgery is against the policy - 2. Tape the medal to the
client and allow the client to wear the medal
3. The nurse must obtain surgical consent forms for the scheduled surgery. Which
client would not be able to consent legally to surgery?
1. The 65 year old client who cannot read or write
2. The 30 year old who does not understand English
3. The 16 year old who has a fractured ankle
4. The 8- year old who is not oriented to the day - 3. The 16 year old who has a
fractured ankle
4. The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature
2. Take and document intake and output
3. Administer the on-call sedative
4. Complete the preoperative checklist - 4. Complete the preoperative checklist
5. The nurse is interviewing a surgical client in the holding area. Which information
should the nurse report to the anesthesiologist? Select all that apply
1. The client has loose, decayed teeth
2. The client is experiencing anxiety
3. The client smokes two packs of cigarettes a day
4. The client has had a chest x ray which does not show infiltrates
5. The client reports using herbs - 1. The client has loose, decayed teeth
3. The client smokes two packs of cigarettes a day
5. The client reports using herbs
6. Which task would be most appropriate for the nurse to delegate to the UAP
(unlicensed assistive personnel)?
1. Complete the preop checklist
2. Assess the client's preop vital signs
, 3. Teach the client about coughing and deep breathing
4. Assist the client to remove clothing and jewelry - 4. Assist the client to remove
clothing and jewelry
7. The nurse is assessing a client in the day surgery unit who states "I am really
afraid of having this surgery. I'm afraid of what they will find." Which statement would
be the best therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about the surgery."
3. "Tell me about your fears of having this surgery."
4. "I understand how you feel, surgery is frightening." - 3. "Tell me about your fears
of having this surgery."
8. The 68 year old client is scheduled for intestinal surgery does not have clear fecal
contents after 3 tap water enemas. Which intervention should the nurse implement
first?
1. Notify the surgeon of the client's status
2. Continue giving enemas until clear
3. Increase the client's fluid IV rate
4. Obtain STAT serum electrolytes - 1. Notify the surgeon of the client's status
9. The nurse is caring for a male client scheduled for abdominal surgery. Which
interventions should the nurse include in the plan of care? Select all that apply
1. Perform passive ROM exercises
2. Discuss how to cough and deep breathe effectively
3. Tell the client he can have a meal in the PACU
4. Teach ways to manage post op pain
5. Discuss events which occur in the post-anesthesia care unit - 2. Discuss how to
cough and deep breathe effectively
4. Teach ways to manage post op pain
5. Discuss events which occur in the post-anesthesia care unit
10. The nurse is caring for a client scheduled for total hip replacement. Which
behavior indicates the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose
and exhale through the mouth
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves
the feet in a circular motion
3. The client uses the incentive spirometer and inhales slowly and deeply so the
piston rises to the preset volume
4. The client gets out of bed by lifting straight upright from the waist and then swings
both legs along the side of the bed - 4. The client gets out of bed by lifting straight
upright from the waist and then swings both legs along the side of the bed
11. The nurse is completing preoperative assessment on a male client who states, "I
am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist
2. Label the client's allergies on the front of the chair
3. Ask the client what happens when he takes codeine
, 4. Document the allergy on the medication administration record - 3. Ask the client
what happens when he takes codeine
12. Which lab result would require immediate intervention by the nurse for the client
scheduled for surgery?
1. Calcium 9.2
2. Bleeding time 2 minutes
3. Hemoglobin 15
4. Potassium 2.4 - 4. Potassium 2.4
13. Which activities are the circulating nurse's responsibilities in the OR?
1. Monitor the position of the client, prepare the surgical site, and ensure the client's
safety
2. Give preop meds in the holding area and monitor the client's response to
anesthesia
3. Prepare sutures; set up the sterile fild, and count all needles and sponges and
instruments
4. Prepare the meds to be administered by the anesthesiologist and change the
tubing for the anesthesia machine - 1. Monitor the position of the client, prepare the
surgical site, and ensure the client's safety
14. The circulating nurse observes the surgical scrub technician remove a sponge
from the edge of the sterile field with a clamp and place the sponge and clamp in a
designated area. Which action should the nurse implement?
1. Place the sponge back where it was
2. Tell the technician to not waste supplies
3. Do nothing because this is the correct procedure
4. Take the sponge out of the room immediately - 3. Do nothing because this is the
correct procedure
16. Which violation of surgical asepsis would require immediate intervention by the
circulating nurse?
1. Surgical supplies were cleaned and sterilized prior to the case
2. The circulating nurse is wearing a long-sleeved sterile gown
3. Masks covering the mouth and nose are being worn by the surgical team
4. The scrub nurse setting up the sterile field is wearing artificial nails - 4. The scrub
nurse setting up the sterile field is wearing artificial nails
17. The nurse identifies the nursing diagnosis "risk for injury related to positioning"
for the client in the operating room. Which nursing intervention should the nurse
implement?
1. Avoid using the cautery unit, which does not have a biomedical tag on it
2. Carefully pad the client's elbows before covering the client with a blanket
3. Apply a warming pad on the OR table before placing the client on the table
4. Check the chart for any prescription or OTC medication use - 2. Carefully pad the
client's elbows before covering the client with a blanket
18. The circulating nurse is positioning clients for surgery. Which client has the
greatest potential for nerve damage?
1. The 16 year old in dorsal recumbent position having an appendectomy
verified with correct question and
answers
1. The nurse requests the client to sign a surgical informed consent form for an
emergency appendectomy. Which statement by the client indicates further teaching
is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - 1. "I will be glad when this is
over so I can go home today."
2. The nurse in the holding area of the surgery department is interviewing a client
who requests to keep his religious medal on during surgery. Which intervention
should the nurse implement?
1. Notify the surgeon about the client's request to wear the medal
2. Tape the medal to the client and allow the client to wear the medal
3. Request the family member take the medal prior to surgery
4. Explain taking the medal to surgery is against the policy - 2. Tape the medal to the
client and allow the client to wear the medal
3. The nurse must obtain surgical consent forms for the scheduled surgery. Which
client would not be able to consent legally to surgery?
1. The 65 year old client who cannot read or write
2. The 30 year old who does not understand English
3. The 16 year old who has a fractured ankle
4. The 8- year old who is not oriented to the day - 3. The 16 year old who has a
fractured ankle
4. The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature
2. Take and document intake and output
3. Administer the on-call sedative
4. Complete the preoperative checklist - 4. Complete the preoperative checklist
5. The nurse is interviewing a surgical client in the holding area. Which information
should the nurse report to the anesthesiologist? Select all that apply
1. The client has loose, decayed teeth
2. The client is experiencing anxiety
3. The client smokes two packs of cigarettes a day
4. The client has had a chest x ray which does not show infiltrates
5. The client reports using herbs - 1. The client has loose, decayed teeth
3. The client smokes two packs of cigarettes a day
5. The client reports using herbs
6. Which task would be most appropriate for the nurse to delegate to the UAP
(unlicensed assistive personnel)?
1. Complete the preop checklist
2. Assess the client's preop vital signs
, 3. Teach the client about coughing and deep breathing
4. Assist the client to remove clothing and jewelry - 4. Assist the client to remove
clothing and jewelry
7. The nurse is assessing a client in the day surgery unit who states "I am really
afraid of having this surgery. I'm afraid of what they will find." Which statement would
be the best therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about the surgery."
3. "Tell me about your fears of having this surgery."
4. "I understand how you feel, surgery is frightening." - 3. "Tell me about your fears
of having this surgery."
8. The 68 year old client is scheduled for intestinal surgery does not have clear fecal
contents after 3 tap water enemas. Which intervention should the nurse implement
first?
1. Notify the surgeon of the client's status
2. Continue giving enemas until clear
3. Increase the client's fluid IV rate
4. Obtain STAT serum electrolytes - 1. Notify the surgeon of the client's status
9. The nurse is caring for a male client scheduled for abdominal surgery. Which
interventions should the nurse include in the plan of care? Select all that apply
1. Perform passive ROM exercises
2. Discuss how to cough and deep breathe effectively
3. Tell the client he can have a meal in the PACU
4. Teach ways to manage post op pain
5. Discuss events which occur in the post-anesthesia care unit - 2. Discuss how to
cough and deep breathe effectively
4. Teach ways to manage post op pain
5. Discuss events which occur in the post-anesthesia care unit
10. The nurse is caring for a client scheduled for total hip replacement. Which
behavior indicates the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose
and exhale through the mouth
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves
the feet in a circular motion
3. The client uses the incentive spirometer and inhales slowly and deeply so the
piston rises to the preset volume
4. The client gets out of bed by lifting straight upright from the waist and then swings
both legs along the side of the bed - 4. The client gets out of bed by lifting straight
upright from the waist and then swings both legs along the side of the bed
11. The nurse is completing preoperative assessment on a male client who states, "I
am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist
2. Label the client's allergies on the front of the chair
3. Ask the client what happens when he takes codeine
, 4. Document the allergy on the medication administration record - 3. Ask the client
what happens when he takes codeine
12. Which lab result would require immediate intervention by the nurse for the client
scheduled for surgery?
1. Calcium 9.2
2. Bleeding time 2 minutes
3. Hemoglobin 15
4. Potassium 2.4 - 4. Potassium 2.4
13. Which activities are the circulating nurse's responsibilities in the OR?
1. Monitor the position of the client, prepare the surgical site, and ensure the client's
safety
2. Give preop meds in the holding area and monitor the client's response to
anesthesia
3. Prepare sutures; set up the sterile fild, and count all needles and sponges and
instruments
4. Prepare the meds to be administered by the anesthesiologist and change the
tubing for the anesthesia machine - 1. Monitor the position of the client, prepare the
surgical site, and ensure the client's safety
14. The circulating nurse observes the surgical scrub technician remove a sponge
from the edge of the sterile field with a clamp and place the sponge and clamp in a
designated area. Which action should the nurse implement?
1. Place the sponge back where it was
2. Tell the technician to not waste supplies
3. Do nothing because this is the correct procedure
4. Take the sponge out of the room immediately - 3. Do nothing because this is the
correct procedure
16. Which violation of surgical asepsis would require immediate intervention by the
circulating nurse?
1. Surgical supplies were cleaned and sterilized prior to the case
2. The circulating nurse is wearing a long-sleeved sterile gown
3. Masks covering the mouth and nose are being worn by the surgical team
4. The scrub nurse setting up the sterile field is wearing artificial nails - 4. The scrub
nurse setting up the sterile field is wearing artificial nails
17. The nurse identifies the nursing diagnosis "risk for injury related to positioning"
for the client in the operating room. Which nursing intervention should the nurse
implement?
1. Avoid using the cautery unit, which does not have a biomedical tag on it
2. Carefully pad the client's elbows before covering the client with a blanket
3. Apply a warming pad on the OR table before placing the client on the table
4. Check the chart for any prescription or OTC medication use - 2. Carefully pad the
client's elbows before covering the client with a blanket
18. The circulating nurse is positioning clients for surgery. Which client has the
greatest potential for nerve damage?
1. The 16 year old in dorsal recumbent position having an appendectomy
