ATI MED-SURG HESI Exit Exam Rated A 2025

ATI MED-SURG HESI Exit Exam Rated A 2025 1 - While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse? Endotracheal cuff pressure greater than 25 cm H20. Decreased lung compliance during ventilation. Bilateral crackles with increased secretions. Restless client who is biting the endotracheal tube. 2 - While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? Administer a nebulizer treatment. Increase oxygen to 6 liters/minute. Assist the client to lie back in bed. Call for an Ambu resuscitating bag. 3 - After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X- ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? Remove the catheter and apply direct pressure for 5 minutes. Initiate intravenous fluids as prescribed. Secure the catheter using aseptic technique. Notify the healthcare provider of the need to reposition the catheter. 4 - While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? Determine if the drainage has an unpleasant odor. Monitor the client's white blood cell count (WBC). Request a culture and sensitivity of the wound. Cleanse the wound with a sterile saline solution. 5-A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? Increase wall suction to eliminate fluctuation in water seal. Give blood from the collection chamber as autotransfusion. Add sterile water to the suction control chamber. Manipulate blood in tubing to drain into chamber. 6-A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.) Portal hypertension. Sodium and water retention. Decreased serum albumin. Abnormal protein metabolism Portosystemic shunting. 7-The nurse is providing care for a client with a draining postoperative wound infected with methicillin- resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take? Encourage increased oral fluids. Provide high-protein snacks. Change the wound dressing. Administer prescribed antibiotics. 8-A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.) Raisin bran muffins. Bowl of oatmeal. Cup of raspberries. Scrambled eggs. Bacon slices. 9 - When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? Wash hands frequently. Avoid drinking lake water. Do not share personal products. Wear long sleeves and pants. 10 - Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who is immobile on prescribed bedrest. has pressure ulcers on several toes. has diminished pedal pulse volume. is confused and tries to climb out of bed