ATI Standard Quiz- Medical surgical Final
A nurse is caring for a client who is to have his chest tube removed. Which of the
following actions should the nurse take?
A. Cover the insertion site with a hydrocolloid dressing after removal
B. Provide pain medication immediately after removal
C. Instruct the client to perform the Valsalva maneuver during removal
D. Delegate removal of the chest tube to a LPN - ANSWER C
The nurse should instruct the patient to perform the Valsalva maneuver during
removal to maintain the appropriate amount of negative pressure in the chest to
prevent air entry into the pleural space.
A nurse is caring for a client who begins having a tonic clonic seizure while sitting
in a chair at the bedside. Which of the following actions should the nurse take
first?
A. Provide oxygen
B. Place the client in a side lying position
C. Provide privacy
D. Lower the client to the floor - ANSWER D
A nurse is teaching a client how to perform a breast self exam. The nurse should
identify which of the following findings as an indication of breast cancer?
A. Lumps that are mobile and tender upon palpation prior to period
B. Multiple round masses that are tender and found in both breasts
C. Bilaterally darkened areolas
D. A nontender, hard lump that is palpated in one breast - ANSWER D
,A nurse is preparing to change the bed linens of a client who has AIDS and is
continent of stool Which of the following PPE should the nurse don prior to
providing client care (SATA)?
A. Gown
B. Gloves
C. Mask
D. Hair cover
E. Goggles - ANSWER AB
A nurse is assessing a client who has a fractured left femur and is in skeletal
traction. Which of the following findings should the nurse report to provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in left leg. - ANSWER C
A nurse is providing teaching about antiretroviral medication therapy to a client
who has a new diagnosis of AIDS. Which of the following statements should the
nurse include in the teaching?
A. Your provider will prescribed one single antiretroviral medication at a time
B. You should take antiretroviral medications on a routine schedule
C. You should increase your intake of raw fruits and veggies while taking
antiretroviral meds
D. Your provider will prescribed antiretroviral therapy to kill the HIV virus -
ANSWER B
, A nurse is caring for a client who is 72 hr postoperative following an above the
knee amputation. Which of the following actions should the nurse take?
A. Elevate the residual limb on a soft pillow
B. Assist the client to a prone position every 4 hour.
C. Reapply a bandage to the residual limb every 12 hour
D. Apply dressings to the site in a proximal to distal direction - ANSWER
B
The nurse should assist the client to a prone position for 20-30 min every 3-4 hour
following an amputation because it reduces the risk for flexion contractures
A home health nurse enters a clients home and finds a used insulin syringe, without
a cap, on the table. Which of the following action should the nurse take?
A. Recap the needle on the syringe
B. Schedule a nurse to administer future injections for this client
C. Explain to the client that the syringe should be disposed of in the bathroom trash
can
D. Place the syringe in a puncture proof disposal container - ANSWER D
A nurse is caring for a client who has type 1 DM and a cap glucose reading of 48.
Which of the following findings should the nurse expect?
A. Kussmaul respirations
B. Diaphoresis
C. Decreased skin turgor
D. Ketouria - ANSWER B
A nurse should expect a client who has a blood glucose level below 70 to exhibit
manifestations of hypoglycemia. Expecting findings associated with hypoglycemia
include weakness, hunger, diaphoresis, nausea, shakiness and confusion
A nurse is caring for a client who is to have his chest tube removed. Which of the
following actions should the nurse take?
A. Cover the insertion site with a hydrocolloid dressing after removal
B. Provide pain medication immediately after removal
C. Instruct the client to perform the Valsalva maneuver during removal
D. Delegate removal of the chest tube to a LPN - ANSWER C
The nurse should instruct the patient to perform the Valsalva maneuver during
removal to maintain the appropriate amount of negative pressure in the chest to
prevent air entry into the pleural space.
A nurse is caring for a client who begins having a tonic clonic seizure while sitting
in a chair at the bedside. Which of the following actions should the nurse take
first?
A. Provide oxygen
B. Place the client in a side lying position
C. Provide privacy
D. Lower the client to the floor - ANSWER D
A nurse is teaching a client how to perform a breast self exam. The nurse should
identify which of the following findings as an indication of breast cancer?
A. Lumps that are mobile and tender upon palpation prior to period
B. Multiple round masses that are tender and found in both breasts
C. Bilaterally darkened areolas
D. A nontender, hard lump that is palpated in one breast - ANSWER D
,A nurse is preparing to change the bed linens of a client who has AIDS and is
continent of stool Which of the following PPE should the nurse don prior to
providing client care (SATA)?
A. Gown
B. Gloves
C. Mask
D. Hair cover
E. Goggles - ANSWER AB
A nurse is assessing a client who has a fractured left femur and is in skeletal
traction. Which of the following findings should the nurse report to provider?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in left leg. - ANSWER C
A nurse is providing teaching about antiretroviral medication therapy to a client
who has a new diagnosis of AIDS. Which of the following statements should the
nurse include in the teaching?
A. Your provider will prescribed one single antiretroviral medication at a time
B. You should take antiretroviral medications on a routine schedule
C. You should increase your intake of raw fruits and veggies while taking
antiretroviral meds
D. Your provider will prescribed antiretroviral therapy to kill the HIV virus -
ANSWER B
, A nurse is caring for a client who is 72 hr postoperative following an above the
knee amputation. Which of the following actions should the nurse take?
A. Elevate the residual limb on a soft pillow
B. Assist the client to a prone position every 4 hour.
C. Reapply a bandage to the residual limb every 12 hour
D. Apply dressings to the site in a proximal to distal direction - ANSWER
B
The nurse should assist the client to a prone position for 20-30 min every 3-4 hour
following an amputation because it reduces the risk for flexion contractures
A home health nurse enters a clients home and finds a used insulin syringe, without
a cap, on the table. Which of the following action should the nurse take?
A. Recap the needle on the syringe
B. Schedule a nurse to administer future injections for this client
C. Explain to the client that the syringe should be disposed of in the bathroom trash
can
D. Place the syringe in a puncture proof disposal container - ANSWER D
A nurse is caring for a client who has type 1 DM and a cap glucose reading of 48.
Which of the following findings should the nurse expect?
A. Kussmaul respirations
B. Diaphoresis
C. Decreased skin turgor
D. Ketouria - ANSWER B
A nurse should expect a client who has a blood glucose level below 70 to exhibit
manifestations of hypoglycemia. Expecting findings associated with hypoglycemia
include weakness, hunger, diaphoresis, nausea, shakiness and confusion
