ATI Med-Surg Proctored pt.I (2024) Exam Questions and Complete Solutions

1. A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Which of the following actions should the nurse plan to take? Ans: Perform the irrigation with sterile water specific for irrigation 2. A nurse is preparing to administer lactated ringer's via continuous IV infu- sion at 200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min should the nurse set the IV pump to administer? Round to near whole number. Ans: 33 gtt/min 3. A nurse is providing discharge teaching to a client who has a new pre- scription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching? Ans: I should lie down when I take this medication. 4. A nurse is providing discharge teaching to an older adult client following a left total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? Ans: Install a raised toilet seat in your bathroom 5. A nurse is planning care for a client following a cardiac catheterization. Which of the following actions should the nurse take? Ans: Maintain the client's affected extremity in extension 6. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? Ans: I will need to have my partner take over shopping for groceries and cooking the meals for us 7. A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? Ans: Decreased BP 8. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse should anticipate a prescription for which of the following IV medication? Ans: Desmopressin 9. A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE inhibitor and reports a nagging dry cough. Which of the following responses by the nurse is appropriate? Ans: Your cough may require that you stop or change your medication 10. A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's? Ans: Using a nicotine trans- dermal patch 11. A nurse is caring for a patient who has a central venous access device and notes the tubing has become disconnected. The client develops dyspnea and tachycardia. Which of the following actions should the nurse take first? Ans: Clamp the catheter 12. A nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care? Ans: Support bony prominences with pillows 13. A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the following actions is the priority for the nurse to take?- Ans: Discuss recommendations for eating + swallowing techniques 14. A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? Ans: Initiate airborne precautions 15. A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? Ans: History of Crohn's disease 16. A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make? Ans: I can give you additional information about the procedure 17. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow. 1 - Obtain venous access using a 19-gauge needle 2 - Obtain the unit of packed RBCs from the blood bank 3 - Verify blood compatibility with another nurse 4 - Initiate transfusion of the unit of packed RBCs 5 - Remain with the client for the first 15 to 30 min of the infusion Ans: 1,2,3,4,5 18. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? Ans: Floss your teeth following each meals 19. A critical care nurse is assessing a client who has severe head injury. In response to painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale scores should the nurse assign the client? Ans: 5 20. A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching? Ans: I can have frozen fruit juice bar for dessert 21. A nurse is preparing to perform ocular irrigation for a client following chemical splash to the eye. Which of the following actions should the nurse plan to take first? Ans: Collect information about the irritant that caused the injury 22. A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately? Ans: Stri- dor 23. A nurse is reviewing the laboratory reports of a client who has acute pan- creatitis. Which of the following findings should the nurse expect? Ans: Elevated blood glucose 24. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect? Ans: Urine specific gravity 1.001 (<1.005) 25. A nurse is planning care for a client who has pulmonary embolism. Which of the following interventions should the nurse include? Ans: Initiate a continuous IV heparin infusion 26. A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include? Ans: Avoid extremely cold or hot temperatures 27. A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which of the following actions should the nurse take first? Ans: Insert a large-bore IV catheter 28. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? Ans: Palpable thrill 29. Ans: 30. A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia? Ans: Muscle weakness 31. A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take? Ans: - Maintain a daily count of the patient's calorie intake 32. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching? Ans: I will expect my stools to be loose 33. A nurse is caring for a client who is receiving total parental nutrition through a central line. The current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the following actions should the nurse take? Ans: Switch the infusion to a 10% dextrose solution 34. A nurse is caring for a client who is 6 hr postoperative following a thy- roidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbal- ances? Ans: Hypocalcemia 35. A nurse is caring for a client who is caregiver for a relative who has chronic disease. Which of the following statements indicates the client is adapting to the role change? Ans: I need to get my blood pressure medicine refilled 36. A nurse is reviewing medications taken at home with a client who has angi- na. Which of the following statements by the client indicates an understanding of the teaching? Ans: I should lie down before taking dose of isosorbide dinitrate 37. A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4in) area of blood on the postoperative dressing. Which of the following actions should the nurse take? Ans: Circle the drainage 38. A nurse is caring for a client who is receiving mechanical ventilation. Which of following interventions should the nurse implement? Ans: Empty water from the ventilator tubing daily 39. A nurse is a planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? Ans: Apply new gloves when alternating between wound care sites 40. A nurse is providing teaching for a client who has tuberculosis and a new prescription for pyrazinamide. The nurse should instruct the client to notify the provider if which of the following adverse effects occurs? Ans: Jaundice 41. A nurse is planning care for a client who has left-sided hemiplegia follow- ing a stroke. Which of the following actions should the nurse include in the plan of care? Ans: Place the plate guard on the client's meal tray 42. A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take? Ans: Point the tip of the syringe toward the top of the ear canal 43. A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? Ans: Ondansetron 44. A nurse is preparing to discharge a client who has halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following Rx with the provider? Ans: May operate a motor vehicle when no longer taking analgesics 45. A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?- Ans: You will need to return in 2 weeks to provide a sputum sample 46. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? Ans: Frothy sputum + a hacking cough 47. A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following interventions should the nurse include in the plan? Ans: - Admin acetaminophen for pain mgmt 48. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse first take? Ans: Check the patient's urine output 49. A nurse is caring for a client who has Parkinson's disease and is pre- scribed a level 1 dysphagia diet. Which of the following items should the nurse remove from the client's tray? Ans: Peanut butter 50. A nurse in a provider's office is teaching a client about the self-manage- ment of GERD. Which of the following instructions should the nurse include?- Ans: Sleep with head of your bed elevated 6 inches 51. A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? Ans: High-pitched sound upon inspiration 52. A nurse is caring for a client who is 2 days postoperative following a be- low-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? Ans: the elastic bandage will prevent excess edema 53. A nurse is planning care for a client who is 8 hour post-op following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first? Ans: Auscultate breath sounds 54. A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan? Ans: You will need 3 follow-up blood tests within 24 month period 55. A nurse is caring for a client who has hypotension, cool clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client? Ans: High-Fowlers 56. A nurse is teaching a client how to use a quad cane for ambulation following a right- hemispheric stroke. Which of the following client actions indicates an understanding of the teaching? Ans: Client advances the weaker leg forward first 57. A nurse is providing discharge teaching for a client who has new tra- cheostomy. Which of the following statements by the client indicates an un- derstanding of the teaching? Ans: I'll insert the obturator after cleaning my stoma 58. A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse iden- tify as contraindications for receiving the medications? Ans: Potassium Ans: 3.2 mEq/L 59. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? Ans: - Glasgow Coma Scale score changes from 14 to 9 60. A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? Ans: I have a hard time brushing my hair 61. A nurse is providing discharge teaching to a client who will be self-admin- istering insulin at home. Which of the following information should the nurse include regarding needle disposal? Ans: you can discard needles in an empty bleach bottle with a lid 62. A nurse is assessing a client who has arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access? Ans: Absence of a bruit 63. A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? Ans: Request an interpreter during the initial assess- ment 64. A nurse is planning care for a client who has un-repaired intertrochanteric fracture and has Buck's traction placed to the affected leg. Which of the following interventions should the nurse include? Ans: Situate the client's heel in the heel of the traction boot 65. A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse take? Ans: Monitor urine output hourly 66. A nurse is planning care for a client who has a central venous access device for intermittent infusions. Which of the following actions should the nurse include in the plan of care? Ans: Flush the catheter using a 10ml syringe 67. A nurse in the emergency department is caring for a client who has a gunshot wound to the abdomen. Which of the following actions should the nurse take first?a Ans: Check the color of the patient's skin 68. A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? Ans: Check the patient's gag reflex 69. A nurse is developing a plan of care for a client who is returning from the PACU following a left below-the-knee amputation. Which of the following interventions should the nurse include in the plan? Ans: Provide the client with a firm mattress 70. A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sick-day rules. Which of the following statements by the client indicates an understanding ofthe teaching? Ans: I will check urine for ketones if my blood glucose is greater than 240 mg/dL 71. A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect? Ans: PaCO2 Ans: 48 mm Hg 72. A nurse is admitting a client to a medical unit following placement of a permanent pacemaker. Which of the following findings requires further assessment by the nurse? Ans: Hiccups 73. A nurse is caring for a client who experienced extensive burns to the arms and torso. Which of the following actions should the nurse take regarding the client's oral nutritional intake? Ans: Encourage the client to eat as many calories as possible 74. A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? Ans: Apply compression stockings to the lower extremities 75. A nurse is caring for a client who has duodenal ulcer. Which of the following actions should the nurse take? Ans: Infuse packed RBCs 76. A nurse is assessing an older adult client at a health fair. Which of the following statements by the client is the nurse's priority? Ans: In the last day, I have had a severe headache and pain around my right eye 77. A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate? Ans: Potas- sium Ans: 6.8 mEq/L 78. A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? Ans: Encourage the client to change positions slowly 79. A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? Ans: Upper Left abdomen 80. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? Ans: Administer IV fluids to the patient 81. A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the following actions should the nurse plan to take? Ans: Complete the transfusion within 2 hour 82. A nurse is planning care for a client who has developed nephrotic syn- drome. Which of the following dietary recommendations should the nurse include? Ans: Decrease protein intake 83. A nurse is caring for an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's abstract thinking? Ans: What is meant by the saying, don't beat around the brush? 84. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take? Ans: Keep the soiled bed linens in the client's room 85. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates the position should the nurse assist the client into for this procedure? Ans: Side-lying [choose diagram w/pt in a fetal position] 86. A nurse is caring for a client who has cervical cancer and a sealed radi- ation implant. Which of the following actions should the nurse take? Ans: Place long-handled forceps at the client's bedside 87. A nurse is teaching a client who has Graves' disease about recognizing the manifestations of the thyroid storm. Which of the following findings should the nurse include in the teaching? Ans: Increased temperature 88. A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? Ans: Muscle twitching 89. A nurse is caring for a client who is receiving epidural analgesics. Which of the following assessment findings in the nurse's priority? Ans: Hypotension 90. A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse's priority to include? Ans: Turn the client to the lateral position during seizure activity 91. A nurse is caring for a client following a below-the knee amputation. The client states. "my life is over." Which of the following responses should the nurse make? Ans: Why do you think your life is over? 92. A nurse in a clinic is providing preventive teaching to an older adult client during a well visit. The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after the age of 60? Ans: Herpes zoster, Influenza, Pneumococcal polysaccharide 93. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? Ans: Place the client's bed at the lowest height 94. A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experienc- ing hypoglycemia? Ans: Increased perspiration 95. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?- Ans: Vomiting upon arousal 96. A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding? Ans: Weight gain 97. A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? Ans: Drink low-fructose cranberry juice; Wipe perineal area from front to back; drink 3L of fluids/day 98. A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer? Ans: Diphenhydramine 99. A home care nurse is planning to use nonpharmacological pain relief measures for an older adult client who has severe chronic back pain. Which of the following guidelines should the nurse use? Ans: Distraction changes the patient's perception of pain, but does not affect the cause 100. A nurse is caring for a female client who is receiving total parental nutrition without fat emulsion. Which of the following findings should the nurse report? Ans: Crackles in the bilateral lung bases