ATI Med-Surg Questions with CORRECT Answers
Question:
A charge nurse is observing a newly licensed nurse administer an IV medication to a
client who has an implanted venous access port. Which of the following observations
requires intervention by the charge nurse?
Answer:
A dressing is not applied to the port site after use. A 22-gauge non-coring needle is used
to access the port. Blood return is noted prior to administering the medication. A
solution of 5 mL heparin 1,000 units/mL has been prepared.
D. A solution of 5 mL heparin 1,000 units/mL has been prepared.
Implanted ports should be flushed after each use and at least once a month when not in
use. This practice is sometimes referred to as "locking" or "de-accessing." It is
performed to prevent the formation of blood clots in the catheter, which would disrupt
the proper functioning of the catheter. The solution of 5 mL heparin should be 100
units/mL; therefore, this action requires intervention by the charge nurse.
Question:
A client is being discharged home with oxygen therapy delivered through a nasal
cannula. Which of the following instructions should the nurse provide to the client and
family members?
Answer:
Use battery-operated equipment for personal care. Apply mineral oil to protect the facial
skin from irritation. Remove the television set from the client's bedroom. Wear cotton
clothing to avoid static electricity.
D. Wear cotton clothing to avoid static electricity.
The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly
combustible gas. The use of oxygen in high concentrations has great combustion
potential and readily fuels fire. Although it will not spontaneously burn or cause an
explosion, it can easily cause a fire in a client's room if it contacts a spark.
,Question:
An emergency room nurse is assessing a client who has a new traumatic brain injury.
The nurse observes extension of the client's arms and legs, pronation of the arms, and
plantar flexion of the feet. Which of the following actions is the nurse's priority?
Answer:
Monitor urinary output Administer an osmotic diuretic Provide supplemental oxygen
Initiate seizure precautions
C. Provide supplemental oxygen
The first action the nurse should take when using the airway, breathing, and circulation
(ABC) approach to client care is to provide supplemental oxygen. The client might
require an artificial airway and mechanical ventilation because these findings indicate
decerebrate positioning, which is associated with brainstem injury and can lead to brain
herniation and death.
Question:
A nurse in an emergency department is assessing a client who sustained a fall off of a
roof. Which of the following findings should the nurse identify as an indication of a
basilar skull fracture?
Answer:
Depressed fracture of the forehead Clear fluid coming from the nares Motor loss on one
side of the body Bleeding from the top of the scalp
B. Clear fluid coming from the nares
Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a
basilar skull fracture.
Question:
A nurse is assessing a client who has a fractured left femur and is in skeletal traction.
Which of the following findings should the nurse report to the provider?
Answer:
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg
C. Chest petechiae
, Question:
The nurse should identify chest petechiae as an indication of fat embolism syndrome.
Clients who have fractures of the long bones such as the femur are at increased risk of
fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets
from the marrow enter into the systemic circulation and are deposited in the lungs. The
nurse should immediately notify the provider because the client could progress to acute
respiratory failure.
Answer:
Blumberg's sign
Question:
A nurse is assessing a client who has cholecystitis. Which of the following findings
should the nurse expect?
Answer:
Ascites Gastrointestinal bleeding Kehr's sign Blumberg's sign
Question:
The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who
has cholecystitis. This response can be an indication of peritoneal inflammation.
Answer:
:B. The nurse should expect to find ascites in a client who has chronic pancreatitis or
pancreatic cancer.
Question:
The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic
cancer.
Answer:
A. Nonproductive cough, fever, and shortness of breath
Question:
The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.
Answer:
B. Lesions on the retina that produce blurred vision
Question:
A charge nurse is observing a newly licensed nurse administer an IV medication to a
client who has an implanted venous access port. Which of the following observations
requires intervention by the charge nurse?
Answer:
A dressing is not applied to the port site after use. A 22-gauge non-coring needle is used
to access the port. Blood return is noted prior to administering the medication. A
solution of 5 mL heparin 1,000 units/mL has been prepared.
D. A solution of 5 mL heparin 1,000 units/mL has been prepared.
Implanted ports should be flushed after each use and at least once a month when not in
use. This practice is sometimes referred to as "locking" or "de-accessing." It is
performed to prevent the formation of blood clots in the catheter, which would disrupt
the proper functioning of the catheter. The solution of 5 mL heparin should be 100
units/mL; therefore, this action requires intervention by the charge nurse.
Question:
A client is being discharged home with oxygen therapy delivered through a nasal
cannula. Which of the following instructions should the nurse provide to the client and
family members?
Answer:
Use battery-operated equipment for personal care. Apply mineral oil to protect the facial
skin from irritation. Remove the television set from the client's bedroom. Wear cotton
clothing to avoid static electricity.
D. Wear cotton clothing to avoid static electricity.
The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly
combustible gas. The use of oxygen in high concentrations has great combustion
potential and readily fuels fire. Although it will not spontaneously burn or cause an
explosion, it can easily cause a fire in a client's room if it contacts a spark.
,Question:
An emergency room nurse is assessing a client who has a new traumatic brain injury.
The nurse observes extension of the client's arms and legs, pronation of the arms, and
plantar flexion of the feet. Which of the following actions is the nurse's priority?
Answer:
Monitor urinary output Administer an osmotic diuretic Provide supplemental oxygen
Initiate seizure precautions
C. Provide supplemental oxygen
The first action the nurse should take when using the airway, breathing, and circulation
(ABC) approach to client care is to provide supplemental oxygen. The client might
require an artificial airway and mechanical ventilation because these findings indicate
decerebrate positioning, which is associated with brainstem injury and can lead to brain
herniation and death.
Question:
A nurse in an emergency department is assessing a client who sustained a fall off of a
roof. Which of the following findings should the nurse identify as an indication of a
basilar skull fracture?
Answer:
Depressed fracture of the forehead Clear fluid coming from the nares Motor loss on one
side of the body Bleeding from the top of the scalp
B. Clear fluid coming from the nares
Cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a
basilar skull fracture.
Question:
A nurse is assessing a client who has a fractured left femur and is in skeletal traction.
Which of the following findings should the nurse report to the provider?
Answer:
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg
C. Chest petechiae
, Question:
The nurse should identify chest petechiae as an indication of fat embolism syndrome.
Clients who have fractures of the long bones such as the femur are at increased risk of
fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets
from the marrow enter into the systemic circulation and are deposited in the lungs. The
nurse should immediately notify the provider because the client could progress to acute
respiratory failure.
Answer:
Blumberg's sign
Question:
A nurse is assessing a client who has cholecystitis. Which of the following findings
should the nurse expect?
Answer:
Ascites Gastrointestinal bleeding Kehr's sign Blumberg's sign
Question:
The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who
has cholecystitis. This response can be an indication of peritoneal inflammation.
Answer:
:B. The nurse should expect to find ascites in a client who has chronic pancreatitis or
pancreatic cancer.
Question:
The nurse should expect to find gastrointestinal bleeding in a client who has pancreatic
cancer.
Answer:
A. Nonproductive cough, fever, and shortness of breath
Question:
The nurse should expect to find a positive Kehr's sign in a client who has liver trauma.
Answer:
B. Lesions on the retina that produce blurred vision
