ATI MED - SURG QUESTIONS WITH 100% VERIFIED ANSWERS WITH RATIONALES (Test Banks)
1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
1) Take temperature once a day. Answer
Rationale:
The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is
present due to the client’s altered immune system.
INCORRECT
2) Wash the armpits and genitals with a
gentle cleanser daily. Answer Rationale:
The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and genitals twice
daily.
INCORRECT
3) Change the litter boxes while wearing
gloves. Answer Rationale:
The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life
threatening to a client who has HIV.
INCORRECT
4) Wash dishes in warm water. Answer
Rationale:
The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.
2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen. Answer Rationale:
Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning. Answer Rationale:
Performing chest physiotherapy mobilizes secretions but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when
suctioning the airway. Answer Rationale:
Prelubricating the suction catheter tip with sterile saline helps to ease the insertion of the catheter, producing
less trauma. However, it has no effect on the tenacity of the client's secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning the
airway. Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on the tenacity of
the client's secretions.
, 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse
and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the
nurse take to promote the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the lower
extremities is a contraindication for leg massage.
2) Obtain a pair of slipper socks for the client. Answer
Rationale:
Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.
INCORRECT
3) Increase the client's oral fluid intake. Answer
Rationale:
Increasing the client's fluid intake will not increase circulation to an area an occlusion impairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a contraindication for applying a heating pad.
INCORRECT
1) Emesis of 100 mL Answer Rationale:
The nurse should recognize postoperative nausea is a complication related to the administration of anesthesia
and should treat the nausea with anti-emetics and provide supportive measures; however, it is not the priority
finding.
INCORRECT
2) Oral temperature of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and encourage deep breathing, coughing, and fluid
intake (if permitted); however, it is not the priority finding to report. The increase in temperature is likely due
to decreased respiratory effort related to the use of anesthesia and should clear with pulmonary hygiene.
3) Thick, red-colored urine Answer
Rationale:
The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be
reported to the provider immediately.
INCORRECT
4) Pain level of 4 on a 0 to 10 rating scale
Answer Rationale:
The nurse should assess for and treat postoperative pain which is an expected finding in the postoperative
client; however it is not the priority finding to report. Specific pain, such as bladder spasms, may indicate
complications however and should be reported to the provider.
, 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a
hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of
the hypothermia blanket?
4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
INCORRECT
1) "I will carry a complex carbohydrate snack with me when I exercise."
Answer Rationale:
The nurse should reinforce that the client should carry a simple carbohydrate such as hard candy or glucose
tablets for use during exercise if the client becomes hypoglycemic.
INCORRECT
2) "I should exercise first thing in the morning before eating breakfast." Answer
Rationale:
The nurse should reinforce that exercise should follow a meal. Exercising first thing in the morning on an
empty stomach places the client at risk for hypoglycemia.
INCORRECT
3) "I should avoid injecting insulin into my thigh if I am going to go running."
Answer Rationale:
The nurse should reinforce that the client should avoid injecting insulin into an area that will soon be exercised
to avoid increasing the absorption rate of the insulin.
4) "I will not exercise if my urine is positive for ketones." Answer Rationale:
The nurse should reinforce that exercise should be avoided if ketones are present in the urine as this indicates
an elevated blood glucose level or ketoacidosis.
, 1) Shivering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can cause the client’s
temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A manifestation of infection is
hyperthermia.
INCORRECT
3) Burns
Answer Rationale:
Burns are associated with the improper use of heating pads, not hypothermia blankets.
INCORRECT
4) Hypervolemia Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk associated with
hyperthermia due to fluid loss.
6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is
postoperative. After calling for assistance, which of the following actions should the nurse take first?
1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.
Which of the following instructions should the nurse include in the teaching?
1) Take temperature once a day. Answer
Rationale:
The nurse should reinforce to the client to take his temperature once a daily to identify if a temperature is
present due to the client’s altered immune system.
INCORRECT
2) Wash the armpits and genitals with a
gentle cleanser daily. Answer Rationale:
The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and genitals twice
daily.
INCORRECT
3) Change the litter boxes while wearing
gloves. Answer Rationale:
The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life
threatening to a client who has HIV.
INCORRECT
4) Wash dishes in warm water. Answer
Rationale:
The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.
2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen. Answer Rationale:
Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning. Answer Rationale:
Performing chest physiotherapy mobilizes secretions but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when
suctioning the airway. Answer Rationale:
Prelubricating the suction catheter tip with sterile saline helps to ease the insertion of the catheter, producing
less trauma. However, it has no effect on the tenacity of the client's secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning the
airway. Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on the tenacity of
the client's secretions.
, 3. Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse
and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the
nurse take to promote the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the lower
extremities is a contraindication for leg massage.
2) Obtain a pair of slipper socks for the client. Answer
Rationale:
Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.
INCORRECT
3) Increase the client's oral fluid intake. Answer
Rationale:
Increasing the client's fluid intake will not increase circulation to an area an occlusion impairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a contraindication for applying a heating pad.
INCORRECT
1) Emesis of 100 mL Answer Rationale:
The nurse should recognize postoperative nausea is a complication related to the administration of anesthesia
and should treat the nausea with anti-emetics and provide supportive measures; however, it is not the priority
finding.
INCORRECT
2) Oral temperature of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and encourage deep breathing, coughing, and fluid
intake (if permitted); however, it is not the priority finding to report. The increase in temperature is likely due
to decreased respiratory effort related to the use of anesthesia and should clear with pulmonary hygiene.
3) Thick, red-colored urine Answer
Rationale:
The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be
reported to the provider immediately.
INCORRECT
4) Pain level of 4 on a 0 to 10 rating scale
Answer Rationale:
The nurse should assess for and treat postoperative pain which is an expected finding in the postoperative
client; however it is not the priority finding to report. Specific pain, such as bladder spasms, may indicate
complications however and should be reported to the provider.
, 5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a
hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of
the hypothermia blanket?
4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
INCORRECT
1) "I will carry a complex carbohydrate snack with me when I exercise."
Answer Rationale:
The nurse should reinforce that the client should carry a simple carbohydrate such as hard candy or glucose
tablets for use during exercise if the client becomes hypoglycemic.
INCORRECT
2) "I should exercise first thing in the morning before eating breakfast." Answer
Rationale:
The nurse should reinforce that exercise should follow a meal. Exercising first thing in the morning on an
empty stomach places the client at risk for hypoglycemia.
INCORRECT
3) "I should avoid injecting insulin into my thigh if I am going to go running."
Answer Rationale:
The nurse should reinforce that the client should avoid injecting insulin into an area that will soon be exercised
to avoid increasing the absorption rate of the insulin.
4) "I will not exercise if my urine is positive for ketones." Answer Rationale:
The nurse should reinforce that exercise should be avoided if ketones are present in the urine as this indicates
an elevated blood glucose level or ketoacidosis.
, 1) Shivering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can cause the client’s
temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A manifestation of infection is
hyperthermia.
INCORRECT
3) Burns
Answer Rationale:
Burns are associated with the improper use of heating pads, not hypothermia blankets.
INCORRECT
4) Hypervolemia Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk associated with
hyperthermia due to fluid loss.
6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of
the following statements by the client indicates an understanding of the teaching?
7. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is
postoperative. After calling for assistance, which of the following actions should the nurse take first?
