ATI Med Surg Proctored 2024
04 September 2024ATI Med Surg Proctored 2024
A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?
Lymphedema (Correct answer)
A nurse is preparing to administer lactated Ringer’s via continuous IV infusion 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?
33 (Correct answer)
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following client statements indicates an understanding of the teaching?
“I should lie down when I take this medication.” (Correct answer)
A nurse is providing discharge teaching to an older adult client following total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
“Install a raised toilet seat in your bathroom.” (Correct answer)
A nurse is planning care for a client following cardiac catheterization. Which of the following actions should the nurse take?
Maintain the client’s affected extremity in extension. (Correct answer)
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?
“I will need to have my partner take over shopping for groceries and cooking the meals for us.” (Correct answer)
A nurse is providing teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
“Wash your perineal area two times each day with antimicrobial soap.” (Correct answer)
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 hr. The nurse should anticipate a prescription for which of the following IV medications?
Desmopressin (Correct answer)
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?
“Your cough may require that you stop or change your medication.” (Correct answer)
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?
Using a nicotine transdermal patch (Correct answer)
A nurse is caring for a client 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?
Turn the client to his left side (Correct answer)
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?
Support bony prominences with pillows (Correct answer)
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?
Discuss recommendations for eating and swallowing techniques (Correct answer)
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)
Initiate airborne precautions (Correct answer)
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?
History of Crohn’s disease (Correct answer)
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?
“I can give you additional information about the procedure.” (Correct answer)
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of actions the nurse should take (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Obtain venous access using a 19-gauge needle
Obtain the unit of packed RBCs from the blood bank
Verify blood compatibility with another nurse
Initiate transfusion of the unit of packed RBCs
Remain with the client for the first 15 to 30 minutes (Correct answers)
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
“I should expect less than 25 mL of secretions per day in the drainage devices.” (Correct answer)
A critical care nurse is assessing a client who has a 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?
5 (Correct answer)
A nurse provides discharge teaching to a client with heart failure and instructs him to limit sodium intake to 2 grams per day. Which of the following statements by the client indicates an understanding of the teaching?
“I can have a frozen fruit juice bar for dessert.” (Correct answer)
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?
Instill 0.9% sodium chloride solution into the affected eye (Correct answer)
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
Stridor (Correct answer)
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
Elevated blood glucose (Correct answer)
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
Urine specific gravity 1.001 (Correct answer)
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
Initiate a continuous IV heparin infusion (Correct answer)
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?
Avoid extremely hot or cold temperatures (Correct answer)
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?
Insert a large-bore IV catheter (Correct answer)
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
Palpable thrill (Correct answer)
A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the following findings indicates hypokalemia?
Muscle weakness (Correct answer)
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
Administer 0.9% sodium chloride (Correct answer)
A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates an understanding of the teaching?
“I will expect my stools to be loose.” (Correct answer)
A nurse is caring for a client who is receiving total parenteral 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?
Switch the infusion to a 10% dextrose solution (Correct answer)
A nurse is caring for a client who is 6 hr postoperative following a thyroidectomy. The client reports tingling and numbness in the hands. The nurse should identify this as a sign of which of the following electrolyte imbalances?
Hypocalcemia (Correct answer)
A nurse in a provider’s office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?
Consult the client before approaching the dog (Correct answer)
A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
“I should lie down before taking a dose of isosorbide dinitrate.” (Correct answer)
A nurse in the post-anesthesia care unit is assessing a client following an appendectomy and finds a 2-cm (3/4-in) area of blood on the postoperative dressing. Which of the following actions should the nurse take?
Apply pressure (Correct answer)
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse implement?
Perform oral care every 2 hrs (Correct answer)
A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?
Apply new gloves when alternating between wound care sites (Correct answer)
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 effects occurs?
Jaundice (Correct answer)
A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?
Provide the client with a short-handed reacher (Correct answer)
A nurse is performing an ear irrigation for a client. Which of the following actions should the nurse take?
Point the tip of the syringe toward the top of the ear canal (Correct answer)
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?
Ondansetron (Correct answer)
A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?
May operate a motor vehicle when no longer taking analgesics (Correct answer)
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following information should the nurse include in the teaching?
“You will need to return in 2 weeks to provide a sputum specimen.” (Correct answer)
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Frothy sputum (Correct answer)
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?
Administer acetaminophen for pain management (Correct answer)
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 take first?
Check the client’s urine output (Correct answer)
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
“I rest in my recliner with my feet elevated for about an hour every afternoon.” (Correct answer)
A nurse in a provider’s office is teaching a client about the self-management of GERD. Which of the following instructions should the nurse include?
“Sleep with the head of your bed elevated 6 inches.” (Correct answer)
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?
High-pitched sound on inspiration (Correct answer)
A nurse is caring for a client who is 2 days postoperative following a below-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?
“The elastic bandage will prevent excessive edema.” (Correct answer)
A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
Auscultate breath sounds (Correct answer)
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?
“You will need three follow-up blood tests within a 24-month period.” (Correct answer)
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea. In which of the following positions should the nurse place the client?
Feet elevated (Correct answer)
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
Dark red granulation tissue (Correct answer)
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
“I’ll cleanse the cannula with half-strength hydrogen peroxide.” (Correct answer)
A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
Potassium 3.2 mEq/L (Correct answer)
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?
Glasgow Coma Scale score changes from 14 to 9 (Correct answer)
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?
“I have a hard time with brushing my hair.” (Correct answer)
A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?
“You can discard needles in an empty bleach bottle with a lid.” (Correct answer)
A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm. Which of the following findings should indicate to the nurse a complication of vascular access?
Absence of a bruit (Correct answer)
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?
Request an interpreter during the initial assessment (Correct answer)
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
Hold breaths 3 to 5 seconds before exhaling (Correct answer)
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?
Monitor urine output hourly (Correct answer)
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?
Flush the catheter using a 10-ml syringe (Correct answer)
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?
Check the color of the client’s skin (Correct answer)
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
Check the client’s gag reflex (Correct answer)
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
“Exhale fully before bringing the inhaler to your lips.” (Correct answer)
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 of the teaching?
“I will check my urine for ketones if my blood glucose is greater than 240 mg/dL.” (Correct answer)
A nurse is reviewing ABG results for a client who has COPD. Which of the following findings should the nurse expect?
PaCO2 48 mm Hg (Correct answer)
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?
Hiccups (Correct answer)
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?
Metformin (Correct answer)
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?
Apply compression stockings to the lower extremities (Correct answer)
A nurse is caring for a client who has a duodenal ulcer. Which of the following actions should the nurse take?
Infuse packed RBCs (Correct answer)
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?
“In the last day, I have had a severe headache and pain around my right eye.” (Correct answer)
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following laboratory findings should the nurse anticipate?
Potassium 6.8 mEq/L (Correct answer)
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?
Encourage the client to change positions slowly (Correct answer)
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?
(B) on top (Correct answer)
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?
Administer IV fluids to the client (Correct answer)
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?
Complete the infusion within 2 hr (Correct answer)
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
Decrease protein intake (Correct answer)
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?
“What is meant by the saying, ‘Don’t beat around the bush?'” (Correct answer)
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
Keep soiled bed linens in the client’s room (Correct answer)
A nurse is preparing a client for a lumbar puncture. Which of the following positions should the nurse assist the client into for this procedure?
(B) Side-lying supine (Correct answer)
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of the following actions should the nurse take?
Place long-handled forceps at the client’s bedside (Correct answer)
A nurse is teaching a client who has Graves’ disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
Increased temperature (Correct answer)
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?
Muscle twitching (Correct answer)
A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify which of the following rhythms indicates bradycardia?
(A) Image showing a bradycardic rhythm (Correct answer)
A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse’s priority?
Hypotension (Correct answer)
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurse’s priority to include?
Turn the client to the lateral position during seizure activity (Correct answer)
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?
“Why do you think your life is over?” (Correct answer)
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 age 60? (Select all that apply.)
Pneumococcal polysaccharide (Correct answer)
Influenza (Correct answer)
Herpes zoster (Correct answer)
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Place the client’s bed at the lowest height (Correct answer)
A nurse is assessing a client who has a new diagnosis of type 1 DM. Which of the following findings indicate that the client is experiencing hypoglycemia?
Increased perspiration (Correct answer)
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?
Vomiting upon arousal (Correct answer)
A nurse is caring for a client who has hypervolemia. Which of the following is an expected assessment finding?
Weight gain (Correct answer)
A nurse is teaching about measures to prevent recurring UTIs with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Wipe the perineal area from front to back after urinating (Correct answer)
Drink 3 L of fluids daily (Correct answer)
Drink low-fructose cranberry juice (Correct answer)
A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following the administration of IV contrast dye. Which of the following medications should the nurse plan to administer?
Diphenhydramine (Correct answer)
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?
Distraction changes the client’s perception of pain, but doesn’t affect the cause (Correct answer)
A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report?
Crackles in the bilateral lung bases (Correct answer)
