ATI Med Surg Proctored Exam Questions and Complete Solutions.

1. A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon? a. Heart rate 90/min b. Absent bowel sounds c. Hgb 8.2 g/dl d. Gastric pH of 3.Ans: c. Hgb 8.2 g/dl RationaleAns: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging. 2. A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer? a. Desmopressin b. Regular insulin c. Furosemide d. Lithium carbonatAns: a. Desmopressin RationaleAns: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vaso- pressin increase ADH and to stop patient on urinating. 3. DesmopressinAns: treat bedwetting 4. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor? a. Fasting blood glucose b. Stool for occult blood - GI bleed c. Urine for white blood cells d. Serum calcium RationaleAns:Ans: b. Stool for occult blood - GI bleed RationaleAns: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry stools, abdominal pain) 5. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) a. Obtain a sputum sample for culture b. Prepare the client for a chest x-ray c. Initiate airborne precautions d. Administer ondansetron.Ans: Initiate airborne precautions 6. A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse involve in the plan of care?Ans: Check the client's urine specific gravity. RationaleAns: to assess for fluid volume overload. 7. A nurse is providing teaching to a client who has Addison's disease about healthy snack foods. Which of the following food choices by the client indi- cates an understanding of the teaching?Ans: Turkey and cheese sandwich RationaleAns: high in protein, carbohydrates, and sodium. A client who has Addison's requires a diet low in potassium, and high in protein, carbs, and sodium 8. Addison's diseaseAns: occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone 9. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. The nurse should understand that which of the following lab- oratory values is consistent with diabetic ketoacidosis?Ans: Bicarbonate level 12 mEq/L RationaleAns: DKA patients have bicarbonate levels less than 15 10. A nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings should indicate to the nurse that the client has hyperglycemia?Ans: Increased urination RationaleAns: increased urination/polyuria, is a manifestation of hyperglycemia due to a 11. A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which of the following findings should the nurse expectAns: - Nonresponsive Command 12. A nurse is collecting data from a client who has coronary artery disease. Which of the following manifestations should the nurse identify as an indica- tion that the client has anginaAns: - Chest Discomfort Radiated - Pain lasting less that 15mins - Pain that is relieved with res 13. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?Ans: - Examine your testicles after a warm shower 14. A nurse is collecting data from a client who has tuberculosis and started combination therapy 2months ago. Which of the following diagnostic results indicates that the client is adhering to the medication regimen.Ans: - A negative sputum culture 15. A nurse is collecting data from a client who has bacterial meningitis. Which of the following findings should the nurse expect?Ans: - Severe Headache 16. ) A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the client indicated an understanding of the teaching- Ans: - I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize 17. A nurse is reinforcing teaching with a male client who has right sided hemiparesis about preforming ADL's. Which of the following instructions should the nurse include in the teachingAns: - Comb your hair with the unaffected arm 18. A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of dyspnea. Which of the following instructions should the nurse include?Ans: - Used the pursed lip breathing technique 19. A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity. Which of the following instructions should the nurse include in the teachingAns: - Apply elastic support hoes before getting out of bed in the morning 20. 11) A nurse is preparing to transfer a client from a bed to chair following a total knee arthroplasty. The client has a prescription for partial weight bearing. Which of the following actions should the nurse takeAns: - Flex at the hip and knees before transferring the client 21. A nurse is reinforcing teaching with a client who is scheduled for a thora- centesis to remove pleural =uid. Which of the following information should the nurse include in the teachingAns: - You will lean forward on the over bed table for this procedure 22. A nurse is reinforcing teaching with a newly licensed nurse about promot- ing sleep in older adult clients who have Alzheimer's disease. Which of the following statements by the newly licensed nurse indicated an understanding of the teachingAns: - I will provide the client with a light snack of cheese and crackers at bed time 23. A nurse is reinforcing teaching with a client who is in early stage stages of COPD and wants to use nicotine chewing gum to help him stop smoking. Which of the following recommendations should the nurse makeAns: - Do not eat or drink anything 15min before or after chewing the gum 24. A nurse is reinforcing teaching about foot care with a client who has a new diagnosis of diabetes mellitus, which of the following statements by the client indicates an understanding of the instructionsAns: - I'll prop my feet up while im watching television 25. A nurse is contributing to the plan of care for a client who has a neurogenic bladder following a spinal cord injury. Which of the following interventions should the nurse include in the plan to develop bladder controlAns: - Stroke the inner thigh 26. ) A nurse is reviewing the medical record of a client who has systemic lu- pus erythematosus. Which of the following findings should the nurse expectAns: - Joint pain 27. ) A nurse is planning care for a client who is receiving bolus enteral feedings and is prescribed digoxin and furosemide. Which of the following actions should the nurse takeAns: - Flush the tube with water before and after each medication 28. A nurse is reinforcing teaching about the use of an Oxygen concentrator in the home for a client who has end stage emphysema. Which of the following instructions should the nurse include to promote client safetyAns: - Maintain an electrical back up system 29. A nurse is caring for a client who has type 1 diabetes mellitus and reports hunger and weakness. The clients blood glucose is 50gm/dL. Which of the following actions should the nurse takeAns: -Have the client drink a glass of milk 30. A nurse is assisting a client who has hypertension in making healthy dietary selections regarding sodium intake. Which of the following foods should the nurse instruct the client to avoid?Ans: - Pretzels 31. A nurse is collecting data from a client who has a new diagnosis of pheochromocytoma. Which of the following findings should the nurse expect- Ans: - Hypertension 32. PheochromocytomaAns: a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine 33. A nurse is reinforcing teaching with a client who has gastric bleeding and is to have a gastric lavage by closed system irrigation. Which of the following statements should the nurse include?Ans: - You should expect to be positioned in a semi-upright position 34. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expectAns: - Peripheral Edema - Hepatomegaly - Abdominal Distension 35. A nurse is reinforcing teaching with a client who is experiencing neutrope- nia as a result of chemotherapy. Which of the following information should the nurse includeAns: - Bathe with antimicrobial soap daily - Take temperature daily - Avoid gardening 36. A nurse is reinforcing teaching about home care with the caregiver of a client who is in the early stages of Alzheimer's disease. Which of the following information should the nurse includeAns: - Put labels on the kitchen cabinets and drawers 37. A nurse is collecting data from a nurse who has sodium level of 128mEq/L. Which of the following findings should the nurse expectAns: - Mental Confusion 38. A nurse is reinforcing teaching with a client who has prescription for clopidogrel following a thrombotic stroke. Which of the following information should the nurse include in the teachingAns: - The medication prevents Clot forma- tion 39. A nurse is reinforcing teaching with a client who is recovering from severe diarrhea and is ready to resume eating solid foods. Which of the following food items should the nurse recommend?Ans: - Yogurt 40. A nurse is reinforcing teaching about foods high in calcium with a client who has hypocalcemia. Which of the following foods should the nurse recom- mend as containing the most calciumAns: - 3oz canned salmon 41. A nurse is reinforcing teaching with the caregiver of a client who has a visual impairment due to macular degeneration. Which of the following com- ments by the client's caregiver indicates an understanding of the teachingAns: - I will close the blinds to manage glare 42. A nurse is preparing to perform a closed irrigation of an indwelling urinary catheter for a client who had abdominal surgery. Which of the following actions should the nurse plan to takeAns: - Stop the irrigation if resistance is felt during =uid instillation 43. A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest drainage system connected to low suction. For which of the following findings should the nurse notify the charge nurseAns: - Persistent bubbling in the water-seal chamber 44. A nurse in a long term facility is delegating client care tasks to staff members. Which of the following tasks should the nurse assign to an assistive personnel (AP)?Ans: - Document a client's output for the shift 45. A nurse is caring for a client who has heart failure and a new prescription for furosemide. The nurse should monitor the client for which of the following manifestations as an adverse effect of the medication.Ans: - Tinnitus 46. A nurse is collecting data from a client who has acute cholecystitis. Which of the following manifestations should the nurse expectAns: - Pain radiating to the right shoulder 47. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?Ans: - Fruity breath odor 48. A nurse is caring for a client who is preoperative and does not speak the same language as the nurse. Which of the following actions should the nurse takeAns: 49. A nurse is caring for a client who is scheduled for a right total hip arthroplasty. Which of the following actions should the nurse take prior to the procedure?Ans: - Collect data from the client about any allergies - Ask the client to state her first and last name - Verify the client has signed the consent form is correct 50. A nurse is reinforcing teaching with a client who has hypertension and a prescription for Lisinopril. Which of the following information should the nurse include in the teachingAns: - Report a persistent cough 51. A nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes that the IV site is red, warm, and painful to the touch. Which of the following actions should the nurse take?Ans: - Discontinue the IV and apply a warm, moist compress to the site 52. A nurse is caring for a client who has type1 diabetes mellitus and has undergone a below the knee amputation. Which of the following is the highest priority findingsAns: Skin =ap of the residual limb is cool to the touch 53. A nurse is reinforcing teaching before preforming a 12 leafd ECG for a client who has angina pectoris. Which of the following instructions should the nurse include in the teachingAns: - Lie still and relax for the procedure 54. A nurse is reinforcing teaching about mammograms with an adult client who is postmenopausal. Which of the following statements indicates to the nurse that the client understands the teaching?Ans: - I should have a mammogram every 1-2 years 55. A nurse is contributing to the plan of care for a client who is in skeletal traction. Which of the following interventions should the nurse includeAns: - Keep the clients body centered in the bed 56. A nurse is collecting data from a client who reports amenorrhea and insomnia. Which of the following data should the nurse report to the provider. Click on exhibitAns: - T4 57. A nurse is assisting a client who is on bed rest to preform isometric exercises. Which of the following actions should the nurse takeAns: - Instruct the client to tighten and then relax muscles repeatedly 58. isometric exercisesAns: Involves muscle contraction w/o shortening (ie, no move- ment or a min. shortening of muscle fibers). Ex - contracting quadriceps/gluteal muscles. 59. A nurse is reinforcing teaching with a client who has a new prescription for Simvastin. Which of the following adverse effects should the nurse include in the teachingAns: - Myalgia 60. Simvastin (Zocor) Atorvastatin (Lipitor) UsesAns: They work by blocking an enzyme that is needed by the body to make cholesterol. Thus, less cholesterol is made. decreases LDL (bad) and triglycerides in blood increases HDL (good) 61. A nurse is reinforcing teaching about the prevention of STI's with a client who is sexually active. Which of the following information should the nurse include in the teachingAns: - Inserting polyurethane female condom is effectivefor prevention of STI's 62. polyurethane female condomAns: an effective contraceptive, provides a physical barrier that prevents exposure to genital secretions containing HIV, such as semen and vaginal fluid, and is inserted by the woman 63. A nurse is assisting with the admission of a client who has pertussis. Which of the following isolation precautions should the nurse implementAns: - Droplet 64. A nurse is reinforcing teaching with a client who is scheduled for an EEG. Which of the following information should the nurse include in the teachingAns: - Shampoo your hair the night before 65. A nurse is assisting a client to move from a bed to a wheelchair. The client had a total knee arthroplasty 2 days ago and reports generalized weakness. Which of the following is an appropriate action by the nurseAns: - Lock the wheels of the bed and the wheelchair 66. A nurse is reinforcing postoperative teaching with a client who is sched- uled for a cataract surgery on his right eye. Which of the following instructions should the nurse includeAns: - Wear protective eye shield while sleeping 67. A nurse is reinforcing teaching with a client who has chronic renal failure and is prescribed epoetin alfa. Which of the following information should the nurse include in the teachingAns: - Epoetin Alfa can reduce your need for a blood transfusion 68. A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to seeAns: - A client who has chest tubes and an oxygen Sat of 90% 69. A nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For which of the following adverse effects should the nurse monitorAns: - Muscle Weakness 70. A nurse is preparing to assist with a client who is scheduled for a bron- choscopy. Which of the following actions should the nurse takeAns: - Administer supplemental oxygen 71. A registered nurse in an acute care facility is caring for a group of clients with the assistance of a LPN. Which of the following tasks should the RN delegate to the LPNAns: - Inserting an NG tube - Monitoring an IV infusion site is correct - Administering IM Medication 72. A nurse is collecting data from a client who has a fracture of the femur. The nurse notes respiratory distress, fever, and petechiae. Which of the following actions should the nurse take after notifying the providerAns: - Place the clients in high fowlers position 73. A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower base of the lungs. The nurse should identify this finding as which of the following lungs soundsAns: - Fine Crackles 74. A nurse is reinforcing teaching with a 73 year old female client above preventing osteoporosis. Which of the following information should the nurse includeAns: - Take 2000 international units of Vit D 75. A nurse is contacting the provider of a client who has heart failure and a potassium level of 3.4 mEq/L. Which of the following client medications should the nurse expect the provider to withholdAns: - Digoxin 76. ) A nurse is collecting data from a client who has left homonymous hemi- anopia following a stroke. Which of the following cclient findings effective management of homonymous hemianopsiaAns: - Eats item from both sides of the lunch tray 77. A nurse is reinforcing discharge teaching with a client who has a new cast. The client is prescribed hydrocodone for pain. The nurse should instruct the client to report immediately which of the following findings to the providerAns: - Swelling of the affected extremity 78. A nurse is contributing to the plan of care for a child who had a stroke and is experiencing dysphagia. Which of the following interventions should the nurse include in the planAns: - Keep the clients glasses of liquid at least two thirds full 79. A nurse is assisting with the care of a client who has cellulitis and is receiving IV Ceftriaxone. During data collection, the nurse notes the client is =ushed and the client reports urticarial. After stopping the IV infusion, which of the following actions should the nurse take firstAns: - Check the clients respirations 80. A nurse is caring for a client who has phantom pain after healing from a below the knee amputation. Which of the following medications should the nurse expect the provider to prescribe to relieve the clients pain.Ans: - Pregablin 81. PregablinAns: Anticonvulsant 82. Pregablin and GabapentinAns: Give examples of GABA analogs used to manage seizure 83. A nurse is implementing transmission prevention measures for a client who has active tuberculosis. Which of the following measures should the nurse includAns: - Place surgical mask on the client when transporting to other de- partments 84. A nurse is reinforcing teaching about foods that can cause migraines with a client who has a history of migraine headaches. Which of the following foods should the nurse instruct the clients to avoid.Ans: - Chocolate - Oranges - Artificial sweeteners 85. A nurse is reinforcing teaching with a newly licensed nurse about enoxa- parin. The nurse should include in the teaching that which of the following medications can interact with enoxaparinAns: - Clopidogrel - Asprin - Ginko Biloba 86. A nurse is assisting in the planning of a health education class for a group of older adult clients. Which of the following recommendations should the nurse includeAns: - Obtain pneumococcal immunization 87. A nurse is caring for a newly admitted client who has a wound infected with MRSA. Which of the following precautions should the nurse takeAns: - Place the client in a room with another client who has MRSA - Use dedicated equipment for the client is correct - Wear gloves when client contact will occur - Wear protective gown when entering the clients room 88. A nurse is preparing to administer eardrops to an adult client who has otitis media. Which of the following actions should the nurse plan to take.Ans: - Warm the bottle by holding it in the palm for 5mins before administering 89. A nurse is collecting data from a client who has diabetes mellitus and a blood glucose level of 61 mg/dL. Which of the following findings should the nurse expectAns: - Difficulty contracting 90. A nurse is collecting data from a client who had a stroke that affected the right side of his brain. Which of the following findings should the nurse expectAns: 91. right hemisphere of brainAns: The right hemisphere of the brain is responsible for control of the left side of the body, and is the more artistic and creative side of the brain. 92. A nurse is caring for a client who has cancer and is scheduled for pt CT scan. The client states she does not want to have the scan done since she has decided to stop treatment. Which of the following statements should the nurse makeAns: - I will inform your provider that you can have chosen not to have the CT Scan preformed 93. A nurse is collecting data from a client who reports dizziness, vertigo, and is preforming the Romberg test. Which of the following instructions should the nurse give the clients about this test.Ans: - Open your eyes 94. Romberg testAns: -ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected findingAns: client should be able to stand with minimal swaying for at least 5 seconds 95. A nurse is reinforcing teaching with a client who has a history of calcium oxalate, kidey stones. Which of the following statements by the client indicates an understanding of the instructionsAns: - I'll be sure to eliminate peanuts from my diet 96. A nurse examining a client's rhythm strips notices no visible P waves but many small, erratic spikes throughout the strip as well as variable ventricular rate. The nurse should identify and report this pattern as which of the following dysrhythmias?Ans: - Atrial Fibrillation 97. A nurse is preparing to obtain informed consent for a client who is sched- uled to have a total laryngectomy with a tracheostomy. The nurse should iden- tify that which of the following client statements indicates an understanding of the procedurAns: - There will be a hole in my neck after this procedure 98. A nurse is administering a tap water enema to a client who has constipa- tion. The client reports abdominal cramping during instillation of the enema. Which of the following actions should the nurse takeAns: - Slow the rate of =uid =ow