Advanced Med-Surg ATI - Version B Graded A 2025

1. A Critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client? 1. 2 2. 5 3. 10 4. 13 2. No question 3. No question 4. nurse is preparing to administer a unit of packed RBCs (Unable to read) a. Obtain the client’s first set of vital signs 1 hr. after b. Initiate venous access with a 21-gauge needle c. Administer the unit of packed RBCs over 1 hr. d. Use Y tubing with 0.9% sodium chloride when administering the 5. A nurse is planning care for a client who has upper gastrointestinal bleeding during (Unable to read) nurse plan to take? a. Insert large bore NG tube b. Ensure that the client has 22-gauge IV line in place c. Provide ketorolac for abdominal pain d. Administer nitroprusside IV based on client’s weight 6. A nurse is caring for a client who has intractable vomiting. The client’s ABG findings are pH 7.8 HCO3 35 mEq Pao2 90mm Hg. The nurse should identify these findings as indicating which of the following acid base Imbalances? a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis 7. The nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? a. “Your breathing pattern causes this” b. “Suction pressure that is too high causes this” c. “This means your lung is fully expanded” d. “This indicates a possible leak” 8. No question 9. A nurse is reviewing the laboratory result report (Unable to read) a. Decreased serum amylase b. Elevated serum calcium c. Decreased erythrocyte sedimentation rate d. Elevated blood glucose level 10. A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following should the nurse do first? a. Flush IV catheter b. Reposition Client’s left arm c. Ensure the tubing connection is secure d. Check the IV site for redness 11. No question 12. A nurse is providing teaching to a client who has left sided heart failure. Which of the following (Unable to read) teaching? a. Neck distention b. Anorexia c. Ankle edema d. Hacking cough 13. No question 14. A nurse is administering packed RBC’s to a client. The nurse (Unable to read) the following actions should the nurse take first? (Patient was having a reaction) 1. Stop the infusion 2. Collect a urine sample 3. Administer oxygen to the client 4. Check the client’s vital signs 15. AA nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following should the nurse include? a. Limit visitation time for the client’s children to 40 minutes a day b. Provide a diet of fresh fruits and vegetables for the client c. Apply new gloves when alternating between wound care sites d. Clean the equipment in the client’s room once per week 16. REPEAT QUESTION. .... A nurse is reviewing the laboratory results of a female client who asks about acupuncture as treatment for chemotherapy-induced nausea and vomiting. Which of the following lavatory results should the nurse identify as a contraindication to receiving acupuncture. 1. Hemoglobin 12 g/dL 2. C-reactive protein 0.7 mg/dL 3. Platelets 160,000/mm3 4. Absolute neutrophil count 500/mm3 17. AA nurse is teaching an adult who is immunocompromised (Unable to read) Patient has HIV which to give? (I think) a. Varicella b. Herpes zoster c. Pneumococcal (I think it's this one cause were not supposed to give live vaccine to immunocompromised HIV patients like MMR or Varicella) d. Measles, mumps rubella 18. AA nurse is assessing a client who is taking digoxin. Which of the following findings should the nurse look for? a. Potassium level of 4.3 mEq/L b. Elevated heart rate c. Digoxin level 0.8 ng/mL d. Appearance of halos around (unable to read) 19. A nurse is assessing a client who reports numbness and tingling of his toes and exhibits a positive Trousseau’s sign. Which of the following electrolyte imbalances should the nurse suspect? 1. Hypocalcemia 2. Hyponatremia 3. Hypermagnesemia 4. Hyperchloremia 20. AA nurse is assessing a client who is taking (Unable to read) usually ACE inhibitors cause that... a. Frequent nonproductive cough b. Frequent painless urination c. Potassium 3.5 mEq/L d. Blood pressure 108/62 mm Hg 21. No question 22. No question 23. No question 24. No question 25. No question 26. REPEAT QUESTION.A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following statements by the client indicates an understanding of the teaching? A. I will inspect my mouth once each week for sores B. I will drink orange juice to increase my vitamin C intake C. I will consume canned soup whenever sores appear in my mouth D. I will rinse my toothbrush with hydrogen peroxide and water after each use 27.27. 28. A nurse is monitoring a client’s heart rhythm following an insertion of a pacemaker. Which of the following should the nurse inspect? (I think it’s A) 29. No question 30. AA nurse is teaching a client who has heart failure. Which of the following responses should the client understand the teaching? A. “I should take ibuprofen for a headache” B. “I can have a total of 4 grams of sodium each day” C. “I will weigh myself at different times of the day to monitor fluid retention” D. “I should be able to have a conversation while exercising” 31. REPEAT QUESTION. A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? A. Place hands on the upper abdomen during inhalation B. Exhale slowly through pursed lips C. Hold breaths about 3 to 5 seconds before exhaling D. Position the mouthpiece 2.5 cm (1 in) from the mouth 32. A nurse is providing teaching to a client and his partner about performing peripheral dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? A. Cloudy effluent B. Generalized abdominal pain C. Increased heart rate D. Fever 33. No question 34. AA nurse is implementing care for a client who is in 8 hr. post-operative following (unable to read) should the nurse plan to perform first? (Catherization?) A. Measure the client’s core temperature B. Examine surgical incision for drainage C. Palpate pulses distal to the graft donor site D. Auscultate breath sounds 35. A nurse is calculating fluid input for a client who is receiving a continuous IV infusion of 0.9% sodium chloride (unable to read) bolus every 4 hours. How many mL did the client receive per IV infusions over the past 24 hours? 3300 mL 36. A nurse is planning care for a client who has a seizure disorder. (Unable to read) A. Wrist restraints B. Oral airway C. Tongue blade D. NG tube 37. AA nurse is caring for a client who is taking propranolol migraines. Which of the following (side effects?) A. Fatigue B. Tachycardia C. Dizziness D. Hypertension E. Shortness of breath( according to pg 201 bottom right in ati book) 38. AA nurse is reviewing the laboratory values of a client. Which of the following values (Unable to read) (TO report?) A. BUN 80 B. Potassium 4.0 C. Serum creatinine 0.8 D. Arterial blood pH 7.45 39. AA nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and service animal? A. Command the dog to sit while talking to the client B. Consult the client before approaching the dog (should be this, not supposed to touch a therapy dog cause it confuses them or something) C. Offer the dog a bowl of water to demonstrate caring D. Pet the dog to demonstrate acceptance 40. REPEAT QUESTION. A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching? A. I will have to wait 2 months before additional saline can be added to my breast expander B. I will perform strength building arm exercises using a 15 pound weight C. I will keep my left arm flexed at the elbow as much as possible D. I should expect less than 25 mL of secretions per day in the drainage devices 41. The nurse is providing preoperative teaching for a client who is having left sided cardiac catheterization. Which of the following should the nurse include in the teaching? A. “You should expect a warm sensation after the injection of contrast dye during the procedure” B. You should plan to remain in bed for 18 hours after the procedure” C. “You will have blood pressure measurements every 5 minutes for the first 2 hours after the procedure” D. “You will receive general anesthesia during the procedure” 42. No question available (probably some sort of operation done on the neck area or extubation) A. Hypoactive bowel sounds B. Loose tracheal secretions C. High pitched sound on inspiration (could indicate obstruction or narrowing of airway) D. Client reports of pain in the incision site 43. AA nurse is caring for a client who is using a ventilator. The client has several family members present (Unable to read) exhibiting agitation. Which of the following actions should the nurse take? (Client was making gestures) A. Apply bilateral wrist restraints B. Begin weaning the client of the ventilator C. Offer the client a pen and paper D. Ask the client’s family to leave the room 44. AA nurse is teaching a client who has diabetes mellitus about foot care. Whichof the following instructions should the nurse include? A. “Wear cotton rather than nylon socks” B. “Wear loose-fitting slippers around the house” C. “Use a heating pad to keep your feet warm at night” D. “Wash your feet twice per day with antibacterial soap and hot water” 45. AA nurse is preparing a client who is to undergo thoracentesis. The nurse should place the client in which of the following positions? A. Upright on the edge of the bed leaning over the bedside table B. Prone position with arms above her head C. On her affected side with her head lowered D. In high fowler’s position with her arms at her side 46. AA triage nurse is assessing an older adult client who has a history of hypertension. Which of the following is an indication that the client is having a transient ischemic attack? (questioning dry mouth and vertigo, but google says these are stroke symptoms) A. Hearing loss B. Dry mouth C. Vertigo D. Aphasia E. Diplopia 47. AA nurse is reviewing a client’s ECG rhythm strip. Which of the following components should the nurse use to measure impulsive sinus node through atrioventricular node? A. PP interval B. PR interval C. QRS Complex D. ST segment 48. AA nurse is caring for a client who sustained a 30% body surface area burn 24 hr. ago. Which of the following (unable to read) the client’s response to fluid retention?