MEDICAL SURGICAL ATI RN BUNDLE FOR ADULTS
WITH RATIONALE ANSWERS.
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
ANSWER Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to
reduce the risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest
drainage system. Which of the following findings is an indication of lung re-
expansion? - ANSWER Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the following values should the nurse identify as a
desired outcome for this therapy? - ANSWER INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke,
myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin
is an anticoagulant, the medication must be monitored to ensure the anticoagulation
is within the therapeutic range and prevent hemorrhage (high levels of
anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is
within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - ANSWER Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the hips
when in a lateral position to no more than 30°. This positioning prevents direct
pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - ANSWER
Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding to report to the provider is restlessness,
which can be an indication the client is experiencing disequilibrium syndrome.
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the
client's blood and can lead to dysrhythmias or seizures. Other manifestations include
nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ANSWER Scan the bladder with a portable
ultrasound.
Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
Page 1 of 14
, MEDICAL SURGICAL ATI RN BUNDLE FOR ADULTS
WITH RATIONALE ANSWERS.
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders presents
the greatest risk to this group of clients? - ANSWER Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client's condition is improving? - ANSWER
Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min.
ago. Which of the following findings should the nurse report to the provider
immediately? - ANSWER Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is stridor. Stridor can indicate a narrowing
airway or possible obstruction caused by edema or laryngeal spasms. The nurse
should report the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago.
Which of the following findings should the nurse report to the provider? - ANSWER
The client reports back pain
Rationale: The nurse should notify the provider if the client reports back pain,
which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANSWER Airborne
Rationale: Airborne precautions are required for clients who have infections due
to micro-organisms that can remain suspended in air for lengthy periods of time,
such as tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for
cervical cancer. Which of the following interventions should the nurse include in the
plan of care? - ANSWER Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the
client's room in case of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy.
Which of the following findings is the nurse's priority? - ANSWER Temperature 38.9°
C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is an elevated temperature. An
elevated temperature is a manifestation of excessive thyroid hormone release, or
thyroid storm, due to an increase in metabolic rate. The nurse should report this
finding immediately to the provider because it can lead to seizures and coma.
Page 2 of 14
WITH RATIONALE ANSWERS.
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
ANSWER Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to
reduce the risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest
drainage system. Which of the following findings is an indication of lung re-
expansion? - ANSWER Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the following values should the nurse identify as a
desired outcome for this therapy? - ANSWER INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke,
myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin
is an anticoagulant, the medication must be monitored to ensure the anticoagulation
is within the therapeutic range and prevent hemorrhage (high levels of
anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is
within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - ANSWER Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the hips
when in a lateral position to no more than 30°. This positioning prevents direct
pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - ANSWER
Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding to report to the provider is restlessness,
which can be an indication the client is experiencing disequilibrium syndrome.
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the
client's blood and can lead to dysrhythmias or seizures. Other manifestations include
nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ANSWER Scan the bladder with a portable
ultrasound.
Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
Page 1 of 14
, MEDICAL SURGICAL ATI RN BUNDLE FOR ADULTS
WITH RATIONALE ANSWERS.
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders presents
the greatest risk to this group of clients? - ANSWER Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client's condition is improving? - ANSWER
Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min.
ago. Which of the following findings should the nurse report to the provider
immediately? - ANSWER Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is stridor. Stridor can indicate a narrowing
airway or possible obstruction caused by edema or laryngeal spasms. The nurse
should report the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago.
Which of the following findings should the nurse report to the provider? - ANSWER
The client reports back pain
Rationale: The nurse should notify the provider if the client reports back pain,
which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANSWER Airborne
Rationale: Airborne precautions are required for clients who have infections due
to micro-organisms that can remain suspended in air for lengthy periods of time,
such as tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for
cervical cancer. Which of the following interventions should the nurse include in the
plan of care? - ANSWER Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the
client's room in case of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy.
Which of the following findings is the nurse's priority? - ANSWER Temperature 38.9°
C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is an elevated temperature. An
elevated temperature is a manifestation of excessive thyroid hormone release, or
thyroid storm, due to an increase in metabolic rate. The nurse should report this
finding immediately to the provider because it can lead to seizures and coma.
Page 2 of 14
