ATI RN ADULT MEDICAL SURGICAL EXAM
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1. A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include?: -
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.
2. 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?: Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
3. 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?: 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.
4. 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?: Change position every
hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony promi-
nences. 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.
5. A nurse is assessing a client following the completion of hemodialy-
sis. Which of the following findings is the nurse's priority to report to the
provider?: 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.
6. 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?: Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is
, ATI RN ADULT MEDICAL SURGICAL EXAM
Study online at https://quizlet.com/_fl9gfv
to assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
7. 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?: 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.
8. 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?: Glucose
272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
9. 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?: 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.
10. 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?-
: 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.
11. A nurse is admitting a client who has active TB. Which of the following
types of transmission precautions should the nurse initiate?: 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.
12. 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?: 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.
13. A nurse is assessing a client who is postoperative following a thyroidecto-
my. Which of the following findings is the nurse's priority?: Temperature 38.9°
C (102° F)
, ATI RN ADULT MEDICAL SURGICAL EXAM
Study online at https://quizlet.com/_fl9gfv
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.
14. A nurse is providing discharge teaching about infection prevention to a
client who has AIDS. Which of the following statements by the client indicates
understanding of the teaching?: "I will no longer floss my teeth after brushing my
teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
15. A nurse is providing teaching to a client who has hypertension and a
new prescription for verapamil. Which of the following information should the
nurse include in the teaching?: "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse
effect of verapamil. The client should increase fiber intake to promote regular bowel
function.
16. A nurse is providing education to a client who is at risk for osteoporosis.
Which of the following instructions should the nurse include?: Walk for 30 min
four times per week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can
help the client prevent osteoporosis.
17. A nurse is providing teaching to a client who is perimenopausal and has a
prescription for hormone replacement therapy. For which of the following?: -
Calf pain
Numbness in the arm
Intense headache
Rationale: Calf pain is correct. Calf pain is an indication of deep-vein thrombosis.
The client should report this finding to the provider immediately.
Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovas-
cular accident, which is an adverse effect of hormone replacement therapy. The
client should report this finding to the provider immediately.
Intense headache is correct. An intense headache can indicate a cerebrovascular
accident, which is an adverse effect of hormone replacement therapy. The client
should report this finding to the provider immediately.
18. A nurse is evaluating the plan of care for four clients after 2 days of
hospitalization. The nurse should identify the need to revise the plan for which
of the following clients?: A client who is postoperative following abdominal surgery
and reports feeling that something "popped" when they coughed
Study online at https://quizlet.com/_fl9gfv
1. A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include?: -
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.
2. 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?: Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
3. 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?: 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.
4. 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?: Change position every
hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony promi-
nences. 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.
5. A nurse is assessing a client following the completion of hemodialy-
sis. Which of the following findings is the nurse's priority to report to the
provider?: 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.
6. 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?: Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is
, ATI RN ADULT MEDICAL SURGICAL EXAM
Study online at https://quizlet.com/_fl9gfv
to assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
7. 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?: 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.
8. 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?: Glucose
272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
9. 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?: 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.
10. 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?-
: 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.
11. A nurse is admitting a client who has active TB. Which of the following
types of transmission precautions should the nurse initiate?: 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.
12. 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?: 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.
13. A nurse is assessing a client who is postoperative following a thyroidecto-
my. Which of the following findings is the nurse's priority?: Temperature 38.9°
C (102° F)
, ATI RN ADULT MEDICAL SURGICAL EXAM
Study online at https://quizlet.com/_fl9gfv
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.
14. A nurse is providing discharge teaching about infection prevention to a
client who has AIDS. Which of the following statements by the client indicates
understanding of the teaching?: "I will no longer floss my teeth after brushing my
teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
15. A nurse is providing teaching to a client who has hypertension and a
new prescription for verapamil. Which of the following information should the
nurse include in the teaching?: "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse
effect of verapamil. The client should increase fiber intake to promote regular bowel
function.
16. A nurse is providing education to a client who is at risk for osteoporosis.
Which of the following instructions should the nurse include?: Walk for 30 min
four times per week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can
help the client prevent osteoporosis.
17. A nurse is providing teaching to a client who is perimenopausal and has a
prescription for hormone replacement therapy. For which of the following?: -
Calf pain
Numbness in the arm
Intense headache
Rationale: Calf pain is correct. Calf pain is an indication of deep-vein thrombosis.
The client should report this finding to the provider immediately.
Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovas-
cular accident, which is an adverse effect of hormone replacement therapy. The
client should report this finding to the provider immediately.
Intense headache is correct. An intense headache can indicate a cerebrovascular
accident, which is an adverse effect of hormone replacement therapy. The client
should report this finding to the provider immediately.
18. A nurse is evaluating the plan of care for four clients after 2 days of
hospitalization. The nurse should identify the need to revise the plan for which
of the following clients?: A client who is postoperative following abdominal surgery
and reports feeling that something "popped" when they coughed
