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MEDICAL SURGICAL ATI PROCTORED
2019 EXAM WITH RATIONALES
THIS STUDY GUIDE MATH WITH THE ACTUAL 2025 EXAM TIPS, DOWNLOAD!!
A nurse is contributing to the plan of care for a client who was admitted to the neurologic unit
following a stroke 3 hours ago. Which of the following interventions should the nurse identify
as the priority.
1) Keep the client in a side-lying position.
2) Maintain the client's body alignment.
3) Assist the client with active range-of- motion exercises.
4) Encourage the client to participate in self care. - answer-1) Keep the client in a side-lying position.
- The greatest risk to the client following a stroke is aspiration. The nurse should position the
client in a lateral, or side-lying position, which will allow any secretions to drain out of the
mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available
in the event that any secretions are present in the oral cavity.
- The nurse should keep the client's body in alignment to maintain joint function and prevent
skin breakdown caused by pressure on bony prominences. However, there is another
intervention that is the priority.
- The nurse should assist the client with active range-of-motion exercises and should provide
passive range-of-motion exercises to the client's affected side to maintain joint mobility and
improve muscle strength. However, there is another intervention that is the priority.
,2
- The nurse should encourage the client to complete self-care to the extent that he is able.
Self-care promotes mobility of the joints and increases the client's feelings of independence
and self-esteem. However, there is another intervention that is the priority.
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the
following findings should the nurse report before administering the medication?
1) Elevated blood pressure
2) Decreased potassium
3) Elevated sodium
4) Decreased urine output - answer-2) Decreased potassium
,3
- The nurse should notify the provider immediately of a decreased potassium level because
potassium is lost when a diuretic such as furosemide is administered, which can cause
hypokalemia.
- The nurse should expect the client who has heart failure to have an elevated blood pressure
and does not need to report this finding to the provider before administering the medication.
Furosemide is a diuretic that should help to lower the client's blood pressure.
- The nurse should report a decreased sodium level to the provider before administering the
medication because furosemide can cause hyponatremia.
- The nurse should expect the client who has heart failure to have a decreased urine output
and does not need to report this finding to the provider before administering the
medication. Furosemide is a diuretic, which should cause an increase in urine output for a
client who has heart failure.
A nurse observes a client who is lying in a bed experiencing a tonic - clonic seizure. Which of the
following actions should the nurse take?
1) Lower the side rails of client's bed.
2) Apply wrist restraints to the client
3) Loosen clothing around the client's neck.
4) Position the client in the semi fowlers position. - answer-3) Loosen clothing around the client's
neck.
, 4
- The nurse should loosen clothing around the client's neck to maintain an open airway and
prevent aspiration.
- The nurse should leave the bed rails up to prevent the client from falling out of bed, which
can cause injury.
- The nurse should not apply restraints that can place the client at risk for a fracture injury.
- The nurse should place the client in a lateral position to allow for the drainage of oral
secretions and to maintain an open airway.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of
rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
1) Sleep on a soft foam mattress.
2) Apply cold packs to the inflamed joints.
3) Participate in high impact exercises.
4) Carry a hand purse rather than a shoulder bag. - answer-2) Apply cold packs to the inflamed
joints.
- The nurse should instruct the client to use both warm and cold packs on inflamed joints to
decrease pain.
- The nurse should instruct the client to sleep on a firm mattress to support the joints.
- The nurse should instruct the client to participate in low-impact aerobic exercises, which
will not inflame the client's joints.
MEDICAL SURGICAL ATI PROCTORED
2019 EXAM WITH RATIONALES
THIS STUDY GUIDE MATH WITH THE ACTUAL 2025 EXAM TIPS, DOWNLOAD!!
A nurse is contributing to the plan of care for a client who was admitted to the neurologic unit
following a stroke 3 hours ago. Which of the following interventions should the nurse identify
as the priority.
1) Keep the client in a side-lying position.
2) Maintain the client's body alignment.
3) Assist the client with active range-of- motion exercises.
4) Encourage the client to participate in self care. - answer-1) Keep the client in a side-lying position.
- The greatest risk to the client following a stroke is aspiration. The nurse should position the
client in a lateral, or side-lying position, which will allow any secretions to drain out of the
mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available
in the event that any secretions are present in the oral cavity.
- The nurse should keep the client's body in alignment to maintain joint function and prevent
skin breakdown caused by pressure on bony prominences. However, there is another
intervention that is the priority.
- The nurse should assist the client with active range-of-motion exercises and should provide
passive range-of-motion exercises to the client's affected side to maintain joint mobility and
improve muscle strength. However, there is another intervention that is the priority.
,2
- The nurse should encourage the client to complete self-care to the extent that he is able.
Self-care promotes mobility of the joints and increases the client's feelings of independence
and self-esteem. However, there is another intervention that is the priority.
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the
following findings should the nurse report before administering the medication?
1) Elevated blood pressure
2) Decreased potassium
3) Elevated sodium
4) Decreased urine output - answer-2) Decreased potassium
,3
- The nurse should notify the provider immediately of a decreased potassium level because
potassium is lost when a diuretic such as furosemide is administered, which can cause
hypokalemia.
- The nurse should expect the client who has heart failure to have an elevated blood pressure
and does not need to report this finding to the provider before administering the medication.
Furosemide is a diuretic that should help to lower the client's blood pressure.
- The nurse should report a decreased sodium level to the provider before administering the
medication because furosemide can cause hyponatremia.
- The nurse should expect the client who has heart failure to have a decreased urine output
and does not need to report this finding to the provider before administering the
medication. Furosemide is a diuretic, which should cause an increase in urine output for a
client who has heart failure.
A nurse observes a client who is lying in a bed experiencing a tonic - clonic seizure. Which of the
following actions should the nurse take?
1) Lower the side rails of client's bed.
2) Apply wrist restraints to the client
3) Loosen clothing around the client's neck.
4) Position the client in the semi fowlers position. - answer-3) Loosen clothing around the client's
neck.
, 4
- The nurse should loosen clothing around the client's neck to maintain an open airway and
prevent aspiration.
- The nurse should leave the bed rails up to prevent the client from falling out of bed, which
can cause injury.
- The nurse should not apply restraints that can place the client at risk for a fracture injury.
- The nurse should place the client in a lateral position to allow for the drainage of oral
secretions and to maintain an open airway.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of
rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
1) Sleep on a soft foam mattress.
2) Apply cold packs to the inflamed joints.
3) Participate in high impact exercises.
4) Carry a hand purse rather than a shoulder bag. - answer-2) Apply cold packs to the inflamed
joints.
- The nurse should instruct the client to use both warm and cold packs on inflamed joints to
decrease pain.
- The nurse should instruct the client to sleep on a firm mattress to support the joints.
- The nurse should instruct the client to participate in low-impact aerobic exercises, which
will not inflame the client's joints.
