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 11-A 4-year-old with acute lymphocytic leukemia (ALL) is receiving chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child? Use sunblock or protective clothing when outdoors Include the child on regular outings with the family Obtain any childhood vaccination that is not up-to-date Use diluted commercial mouthwash with mouth care 12-After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement? Instruct the client to take deep breaths. Place a wedge under the client's hip. Place the client in the Trendelenburg position. Remove the client's legs from the stirrups. 13-A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first? Place a new pad and weigh the pad removed to determine blood loss. Massage the fundus and express clots. Start an IV and begin an oxytocin infusion. Clean the perineal area and encourage her to breastfeed. 14-A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Beta- lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Ans: 67 15-A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) Explain the purpose of a low bacteria diet. Institute contact precautions for staff and visitors. Use standard precautions and wear a mask Monitor the client's white blood cell count. Send wound drainage for culture and sensitivity. 16 - Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis? Glucose and calcium levels. Blood and urine cultures. Electrolytes and hemoglobin. Renal and liver function tests. 17 - An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? Silence the alarm and call the technician. Monitor oxygen saturation levels every 5 minutes. Begin manual ventilation immediately. Call respiratory therapy. 18-A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology? Systemic autoimmune vasculopathy. Muscle fiber degeneration. Impaired neuron function. Autonomic neuropathy. 19 - An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? Multiple-Choice Single-Answer Select your answer from the options on Initiate passive range of motion exercises. Use pictures and gestures to communicate. Facilitate a consultation for speech therapy. Arrange for daily home care assistance. 20 - The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? Employees' job security. Changes in job descriptions. Potential changes in employee benefits. New management's expectations. 21 - After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to an unlicensed assistive personnel (UAP)? Document vital signs of clients in the medical record. Monitor an intravenous infusion rate on an established schedule. Irrigate a urinary catheter with normal saline. Begin wound care for a client after an appendectomy. 22 - The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately? Right ear hearing loss. Intensifying headache. Facial numbness. Difficulty with balance, 23-A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review? Gonorrhea. Toxoplasmosis. Rubella. Group B Streptococcus. 24 - The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes? Prior to exercising. Immediately after meals. During acute illness. Before going to bed. 25 - The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete? Calf diameter. Joint range of motion. Ankle brachial index (ABI). Skin elasticity. 26 - The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur.Which findings should the nurse include that are often the earliest indication of a FES? Pulmonary crackles. Confusion, restlessness. Tachycardia, fever. Petechial rash. 27 - After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply.) Take out dentures and place in a labeled cup. Remove resuscitation equipment from the room Gently close the eyes. Place a small pillow under the head. Apply a body shroud. 28-A female adolescent client is admitted to the hospital because she wrote a suicide note to her teacher at school. On the second day of hospitalization, the nurse asks the client to meet with the treatment team. After the team meeting, the client leaves in tears and goes to her room. Which nursing intervention is best? Explore the client's goals and desire for treatment. Let the client rest quietly in her room for a while. Go to the client's room and ask what happened. Ask the treatment team about the client's behavior. 29 - During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the clients list should the nurse encourage? (Select all that apply.) Natural whole almonds. Plain, air-popped popcorn. Cheddar cheese cubes. Canned fruit in heavy syrup. Lightly salted potato chips. 30 - The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? (Select all that apply.) Maintain the bed flat while sleeping. Cross legs at knee but not at ankle. Avoid prolonged standing or sitting. Use recliner for long periods of sitting. Continue wearing compression stockings. 31-A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? Low blood glucose levels. Ventricular arrhythmias. Profound weight gain. Decreased urinary output. 32 - An older adult woman with advanced Alzheimer's is admitted with severe nausea, vomiting, and diarrhea. The client's caregiver tells the nurse that the client has a history of irritable bowel syndrome, hepatitis A, and Methicillin-resistant Staphylococcus aureus (MRSA). Which intervention is most important for the nurse to implement? Perform hemoccult test on a sample of the client's stool. Clarify with the caregiver the exact location of the MRSA Utilize strict precautions when handling feces. Administer a prescribed PRN antiemetic. 33 - The nurse is assessing a client with Addison's disease who is experiencing weakness, dizziness, disorientation. The nurse observes the client has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure, 94/44, heart rate 132 beats/minute, respirations 22 breaths/minute, and blood pressure 94/44 mmHg. Which intervention should the nurse implement first? Initiate fluid resuscitation. Obtain a blood sample for serum electrolytes. Assess extremity strength and resistance. Begin hourly finger stick glucose levels. 34 - The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 ml. remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report? Peripheral pulses present with full range of motion of both legs. History of vomiting at home for 3 days prior to surgery. Soft abdomen, absent bowel sounds, no bleeding on dressing. Declining to take ice chips for complaints of dry mouth. 35 - The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? Cloudy opacity of the crystalline lens. Recent change in the ability to read and drive after dark. Gradual onset of continuous eye pain and blurred vision Gray-white circle around the iris of both eyes. 36 - The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having had prior sexually transmitted infections. Which response should the nurse provide? Provide counseling that most contraceptives protect against infection. Clarify that all STI’s are transmitted through sexual intercourse. Remain non-judgmental and assure the client of confidentiality. Reassure that complications will not occur if the infection is treated. 37 - An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (Select all that apply.) Altered peripheral tissue perfusion. Fatigue. Fluid volume deficit. Decreased cardiac output. Fluid volume excess. 38 - Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis? Inspect your home for safety hazards. Practice stress reduction techniques. Avoid contact with persons with infections. Use distraction techniques to reduce pain 39-A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider? Electromyography. Allergy test. Complete blood count. Skin biopsy. 40-The nurse is caring for a toddler during a follow-up visit after corticosteroid treatment for minimal change nephrotic syndrome (MCNS). Which finding should the nurse recognize as an early sign of relapse? Tachypnea. Rounded face. Albuminuria. Increased thirst. 41-A client with bone cancer report pain of 10 on a scale of 0 to 10. Thirty minutes after the nurse medicates the client with IV pain medication, the client has no pain relief. Which intervention is most important for the nurse to include in the client’s plan of care? Document any side effects the client experiences from the pain medication Assess client’s pain more frequently to determine amount of ongoing pain Monitor and report break-through pain occurring between pain and medication Administer the prescribed analgesic on regular scheduled around the clock 42-A client arrives to the emergency department after experiencing a syncopal episode. Laboratory results indicate a red blood cell (RBC) count of 1,5 x10°/uL (1.5 x 1012/L) and a hemoglobin of 7 g/dL (70 g/L). The client is diagnosed with pernicious anemia and receives a transfusion of packed red blood cells (PRBC). Which laboratory findings would the nurse expect to provide more pathophysiological evidence of pernicious anemia? (Select all that apply.) High serum B12. Elevated total iron-binding capacity. Deficient folate level. Low reticulocyte count. Macrocytosis. 43-A client who is unconscious is brought by ambulance to the emergency department following an automobile accident. The nurse observes bleeding from the nose and the client's vital signs on arrival are: heart rate 100 beats/minute, respirations 16 breaths/minute, and blood pressure 130/76 mm Hg. Which assessment finding warrants immediate intervention by the nurse? Pupils 3 mm with sluggish response. Halo around blood dropped on gauze. Clots of blood forming within nares Blood pressure decreases to 110/64 mm Hg. 44-A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? (Select all that apply.) Increase oral fluid intake to 1,500 mL daily. Monitor abdominal girth. Provide diet low in phosphorus. Note signs of swelling and edema. Report serum albumin and globulin levels. 45 - An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client? (Choose all that apply.) Family health history. Vegetarian diet. Homosexual lifestyle. Excessive aerobic exercise. History of hypertension. 46 - Which is the best approach for the nurse to use when interviewing a client about sexual abuse? Get the most difficult questions over with first. Begin with questions that are less sensitive in nature. Share personal values to put the client at ease. Ask questions in a vague, non-specific format. 47 - The healthcare provider prescribes a low dose heparin protocol at 18 units/kg/hour for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the pump to deliver how many mL/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Ans: 12 48 - The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? Experiences facial swelling after eating crab. Drank a glass of water in the past 2 hours. Reports left chest wall pain prior to admission. Verbalizes a fear of being in a confined space. 49 - The nurse is planning care for a client who has had a suprapubic resection of the prostate gland. Which nursing problem has the highest priority for this client's care? Pain related to inability to use patient-controlled analgesia. Risk for deficient fluid volume related to NP status. Impaired physical mobility related to multiple drainage devices Risk for decreased cardiac output related to bleeding. 50 - The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? Maintain strict intake and output.