ATI MED SURGE FINAL EXAM| COMPLETE QUESTIONS WITH EXPERT SOLUTIONS|
2026 LATEST UPDATED| A+
1. A nurse is caring for a client who is 4 hr postop following a total vaginal hysterectomy.
2000: Client reports pain as 3 of 0 to 10. Breath sounds clear and present throughout. Three abdominal bandages to
abdomen, dry and intact with no drainage noted. Client voided 90 mL of clear-yellow urine into bedpan. Perineal pad
with small amount of blood, no clots; perineal pad changed at this time. BP: 128/78, Resp: 16, Temp: 98.6°, HR 88,
O2: 97% RA
2400: Client sleeping, arouses to verbal stimuli. Reports pain as 2 on a scale of 0 to 10 with repositioning. Client
voided 125 mL of blood-tinged urine into bedpan. Perineal pad saturated with blood, large clots present.
BP: 106/56, Resp: 14, Temp: 98.6, HR: 102 O2: 95% RA
Click to highlight the findings the nurse should report to the provider immediately.
Client sleeping, arouses to verbal stimuli
Respiratory rate 14/min
Oxygen saturation 95% on room air, breath sounds clear: ANSWER:
Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The
client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and
tachycardia. The nurse should report these findings to the provider.
Client sleeping, arouses to verbal stimuli, respiratory rate 14/min, oxygen saturation 95% on room air, breath sounds
clear, and reports pain as 2 on scale of 0 to 10 are incorrect. These are expected findings. Therefore, the nurse does not
need to report these findings to the provider.
2. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy.
Since discharge, client reports several episodes of dizziness, "fast" heartbeat, and abdominal cramping.
Client states, "I am afraid to eat."
1200: Temp: 97.6°F, HR: 88, Resp: 16 BP: 146/76, O2: 96% RA
,Cyanocobalamin 100 mcg subcutaneous once a month
Ferrous sulfate 65 mg PO every 8 hr
A nurse is providing teaching for the client. Which of the following instructions should the nurse include?
A) Eat five servings of fresh fruit per day.
B) Eat several small meals per day.
C) Avoid highly seasoned foods.
D) Avoid drinking fluids with meals.
E) Maintain a high carbohydrate intake.
F) Consume high-protein snacks.: ANSWER: B, C D, F,
A) Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of
unsweetened cooked or canned fruit per day.
B) Eat several small meals per day is correct. The nurse should instruct the client to eat several small, fr equent
meals instead of three large meals per day.
C) Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of
spices and salt.
D) Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or
after meals.
E) Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because
of reactive hypoglycemia.
F) Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in
carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome.
,3. A nurse is caring for a client who is scheduled for a right knee arthroplasty. 0600:Client is admitted for surgery this
a.m. Client reports understanding of surgery and has no further questions for provider.
0700: Client performed surgical preparation with chlorhexidine at home this a.m. Client states they have had no oral
intake since midnight except sips to take antihypertensive medication. Client states they have not taken NSAIDs for 10
days. IV catheter inserted to right arm with lactated Ringer's infusing at 10 mL/hr.
0800:Preoperative teaching provided. Discussed the following topics with the client: The importance of turning,
coughing, and deep breathing following anesthesia; explained use of incentive spirometer. The need to get out of bed
and ambulate as soon as possible following the surgery; ambulation will be managed by a physical therapist with the
use of a walker or crutches Control of pain following su: ANSWERS: A, B, D
A) "I will need to do the breathing exercises every 1 to 2 hours after the surgery" is correct. The client should
cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative
complications, such as pneumonia.
B) "I will probably be going home with a walker" is correct. It can take 6 weeks for complete recovery from knee
arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks
following surgery.
C) Well, I guess there's no changing my mind about having surgery now" is incorrect. The nurse and the client
reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any
time.
D) "I will be sure to ask for pain medication before my knee starts to hurt too bad" is correct. For optimal control
of postoperative pain, the client should request analgesic medication before the pain becomes severe.
E) "My physical therapy will start after I leave the hospital" is incorrect. Early ambulation leads to improved
postop-erative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The
client should be informed that physical therapy will begin the day of, or the day following, surgery.
, 4. A nurse is teaching a client who has cardiac dysrhythmia about the purpose of undergoing continuous telemetry
monitoring. Which of the following statements by the clients reflects an understanding of t he teaching?
A) "This measures how much blood my heart is pumping."
B) "This identifies if I have a defective heart valve."
C) "This identifies if the pacemaker cells of my heart are working properly."D) "This measures the blood circulating to
my heart muscle.": ANSWER: C "This identifies if the pacemaker cells of my heart are working properly."
Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the
heart muscle.
5. A nurse is preparing to administer Phenytoin 600mg PO daily to a client. The amount available is oral solution
125mg/5 mL. How many mL should the nurse administer? ( Round to nearest whole number): ANSWER: 24Ml
Follow these steps for the Ratio and Proportion method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 600 mg
Step 3: What is the dose available? Dose available = Have 125 mg
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 5 mL Step
6: Set up an equation and solve for X.
HaveDesired = QuantityX
125 mg600 mg = 5 mLX mL
X mL = 24 mL
Step 7: Round if necessary.
Step 8: Determine whether the amount to administer makes sense. If there are 125 mg/5 mL and the prescription reads
600 mg, it makes sense to administer 24 mL. The nurse should administer phenytoin oral solution 24 mL PO.
2026 LATEST UPDATED| A+
1. A nurse is caring for a client who is 4 hr postop following a total vaginal hysterectomy.
2000: Client reports pain as 3 of 0 to 10. Breath sounds clear and present throughout. Three abdominal bandages to
abdomen, dry and intact with no drainage noted. Client voided 90 mL of clear-yellow urine into bedpan. Perineal pad
with small amount of blood, no clots; perineal pad changed at this time. BP: 128/78, Resp: 16, Temp: 98.6°, HR 88,
O2: 97% RA
2400: Client sleeping, arouses to verbal stimuli. Reports pain as 2 on a scale of 0 to 10 with repositioning. Client
voided 125 mL of blood-tinged urine into bedpan. Perineal pad saturated with blood, large clots present.
BP: 106/56, Resp: 14, Temp: 98.6, HR: 102 O2: 95% RA
Click to highlight the findings the nurse should report to the provider immediately.
Client sleeping, arouses to verbal stimuli
Respiratory rate 14/min
Oxygen saturation 95% on room air, breath sounds clear: ANSWER:
Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The
client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and
tachycardia. The nurse should report these findings to the provider.
Client sleeping, arouses to verbal stimuli, respiratory rate 14/min, oxygen saturation 95% on room air, breath sounds
clear, and reports pain as 2 on scale of 0 to 10 are incorrect. These are expected findings. Therefore, the nurse does not
need to report these findings to the provider.
2. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy.
Since discharge, client reports several episodes of dizziness, "fast" heartbeat, and abdominal cramping.
Client states, "I am afraid to eat."
1200: Temp: 97.6°F, HR: 88, Resp: 16 BP: 146/76, O2: 96% RA
,Cyanocobalamin 100 mcg subcutaneous once a month
Ferrous sulfate 65 mg PO every 8 hr
A nurse is providing teaching for the client. Which of the following instructions should the nurse include?
A) Eat five servings of fresh fruit per day.
B) Eat several small meals per day.
C) Avoid highly seasoned foods.
D) Avoid drinking fluids with meals.
E) Maintain a high carbohydrate intake.
F) Consume high-protein snacks.: ANSWER: B, C D, F,
A) Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of
unsweetened cooked or canned fruit per day.
B) Eat several small meals per day is correct. The nurse should instruct the client to eat several small, fr equent
meals instead of three large meals per day.
C) Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of
spices and salt.
D) Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or
after meals.
E) Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because
of reactive hypoglycemia.
F) Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in
carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome.
,3. A nurse is caring for a client who is scheduled for a right knee arthroplasty. 0600:Client is admitted for surgery this
a.m. Client reports understanding of surgery and has no further questions for provider.
0700: Client performed surgical preparation with chlorhexidine at home this a.m. Client states they have had no oral
intake since midnight except sips to take antihypertensive medication. Client states they have not taken NSAIDs for 10
days. IV catheter inserted to right arm with lactated Ringer's infusing at 10 mL/hr.
0800:Preoperative teaching provided. Discussed the following topics with the client: The importance of turning,
coughing, and deep breathing following anesthesia; explained use of incentive spirometer. The need to get out of bed
and ambulate as soon as possible following the surgery; ambulation will be managed by a physical therapist with the
use of a walker or crutches Control of pain following su: ANSWERS: A, B, D
A) "I will need to do the breathing exercises every 1 to 2 hours after the surgery" is correct. The client should
cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative
complications, such as pneumonia.
B) "I will probably be going home with a walker" is correct. It can take 6 weeks for complete recovery from knee
arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks
following surgery.
C) Well, I guess there's no changing my mind about having surgery now" is incorrect. The nurse and the client
reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any
time.
D) "I will be sure to ask for pain medication before my knee starts to hurt too bad" is correct. For optimal control
of postoperative pain, the client should request analgesic medication before the pain becomes severe.
E) "My physical therapy will start after I leave the hospital" is incorrect. Early ambulation leads to improved
postop-erative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The
client should be informed that physical therapy will begin the day of, or the day following, surgery.
, 4. A nurse is teaching a client who has cardiac dysrhythmia about the purpose of undergoing continuous telemetry
monitoring. Which of the following statements by the clients reflects an understanding of t he teaching?
A) "This measures how much blood my heart is pumping."
B) "This identifies if I have a defective heart valve."
C) "This identifies if the pacemaker cells of my heart are working properly."D) "This measures the blood circulating to
my heart muscle.": ANSWER: C "This identifies if the pacemaker cells of my heart are working properly."
Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the
heart muscle.
5. A nurse is preparing to administer Phenytoin 600mg PO daily to a client. The amount available is oral solution
125mg/5 mL. How many mL should the nurse administer? ( Round to nearest whole number): ANSWER: 24Ml
Follow these steps for the Ratio and Proportion method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 600 mg
Step 3: What is the dose available? Dose available = Have 125 mg
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 5 mL Step
6: Set up an equation and solve for X.
HaveDesired = QuantityX
125 mg600 mg = 5 mLX mL
X mL = 24 mL
Step 7: Round if necessary.
Step 8: Determine whether the amount to administer makes sense. If there are 125 mg/5 mL and the prescription reads
600 mg, it makes sense to administer 24 mL. The nurse should administer phenytoin oral solution 24 mL PO.
