ATI MED SURG EXAM
RETAKE
ATI Med-Surg Test s-Multiple Response
1. A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have
emphysema due to inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose
their elasticity, and the diaphragm becomes permanently flattened by
overdistention of the lungs. The muscles of the rib cage also become rigid,
and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their
lack of elasticity, which decreases oxygenation. Clubbing results from these
chronic low blood- oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung
elasticity; consequently, respirations become increasingly shallow and more
rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries
to compensate for less oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the
following clinical manifestations should the nurse expect to observe?
(Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an
increased production of cortisol or by excessive use of corticosteroids.
Buffalo hump, a collection of fat between the shoulders, is a common
manifestation of Cushing's syndrome.Purple striations is correct. Purple
striations on the skin of the abdomen, thighs, and breasts are a common
manifestation of Cushing's syndrome. This is due to the collection of body
fat in these areas.Moon face is correct. Moon face is a common
,ATI MED SURG EXAM
RETAKE
manifestation of
,ATI MED SURG EXAM
RETAKE
Cushing's syndrome. Clients who have this manifestation present with a
round, red, full face.Tremors is incorrect. Tremors are not a common
finding of Cushing's syndrome.Obese extremities is incorrect. Clients
who have Cushing's syndrome have truncal obesity, a protuberant abdomen,
with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that
apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage
fluids, unless contraindicated, to replace the cerebrospinal fluid that
was removed during the procedure and reduce the risk for a
headache.
Monitor the puncture site for a hematoma is correct. The nurse
should monitor and report a hematoma at the insertion site because this
can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary
catheter insertion.
Elevate the client’s head of bed is incorrect. The client should
remain flat in bed for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no
indication for a cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled
for surgery and is to take hydroxyzine preoperatively. Which of the following
effects of the medication should the nurse include in the teaching? (Select all
that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
, ATI MED SURG EXAM
RETAKE
Decreasing anxiety is correct. The nurse should include that
hydroxyzine is an effective antianxiety agent and is used to decrease anxiety
in surgical clients as well as in persons with moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine
is an effective antiemetic and is used to control nausea and vomiting in pre-
and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize
benzodiazepines, such as diazepam (Valium), are used to produce skeletal
muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should
instruct the client that antibiotics administered prior to surgery are used to
diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does
not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct.
Hydroxyzine increases the effects of narcotic pain medications. The nurse
should instruct the client that when it is used for surgical clients, narcotic
requirements may be significantly reduced.
5. A nurse is reinforcing teaching with a client who has type 2 diabetes
mellitus. The nurse determines that teaching has been effective when the
client identifies which of the following manifestations of hypoglycemia?
(Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry vision
3) Tachycardia
INCORRECT
4) Polydipsia
5) Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry
vision, tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors, anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors, anxiety, irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
RETAKE
ATI Med-Surg Test s-Multiple Response
1. A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have
emphysema due to inadequate oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose
their elasticity, and the diaphragm becomes permanently flattened by
overdistention of the lungs. The muscles of the rib cage also become rigid,
and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their
lack of elasticity, which decreases oxygenation. Clubbing results from these
chronic low blood- oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung
elasticity; consequently, respirations become increasingly shallow and more
rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries
to compensate for less oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the
following clinical manifestations should the nurse expect to observe?
(Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an
increased production of cortisol or by excessive use of corticosteroids.
Buffalo hump, a collection of fat between the shoulders, is a common
manifestation of Cushing's syndrome.Purple striations is correct. Purple
striations on the skin of the abdomen, thighs, and breasts are a common
manifestation of Cushing's syndrome. This is due to the collection of body
fat in these areas.Moon face is correct. Moon face is a common
,ATI MED SURG EXAM
RETAKE
manifestation of
,ATI MED SURG EXAM
RETAKE
Cushing's syndrome. Clients who have this manifestation present with a
round, red, full face.Tremors is incorrect. Tremors are not a common
finding of Cushing's syndrome.Obese extremities is incorrect. Clients
who have Cushing's syndrome have truncal obesity, a protuberant abdomen,
with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that
apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage
fluids, unless contraindicated, to replace the cerebrospinal fluid that
was removed during the procedure and reduce the risk for a
headache.
Monitor the puncture site for a hematoma is correct. The nurse
should monitor and report a hematoma at the insertion site because this
can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary
catheter insertion.
Elevate the client’s head of bed is incorrect. The client should
remain flat in bed for 1 hr or more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no
indication for a cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled
for surgery and is to take hydroxyzine preoperatively. Which of the following
effects of the medication should the nurse include in the teaching? (Select all
that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
, ATI MED SURG EXAM
RETAKE
Decreasing anxiety is correct. The nurse should include that
hydroxyzine is an effective antianxiety agent and is used to decrease anxiety
in surgical clients as well as in persons with moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine
is an effective antiemetic and is used to control nausea and vomiting in pre-
and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize
benzodiazepines, such as diazepam (Valium), are used to produce skeletal
muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should
instruct the client that antibiotics administered prior to surgery are used to
diminish the risk of surgical site infections; hydroxyzine, an antiemetic, does
not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct.
Hydroxyzine increases the effects of narcotic pain medications. The nurse
should instruct the client that when it is used for surgical clients, narcotic
requirements may be significantly reduced.
5. A nurse is reinforcing teaching with a client who has type 2 diabetes
mellitus. The nurse determines that teaching has been effective when the
client identifies which of the following manifestations of hypoglycemia?
(Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry vision
3) Tachycardia
INCORRECT
4) Polydipsia
5) Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry
vision, tremors, anxiety, irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors, anxiety, irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors, anxiety, irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
