ATI Proctored Exam 2023 medsurg proctored exam

A school nurse is assessing a child who has been stung by a bee. The child’s hand is swelling and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply)

B) Nausea

D) Urticaria

E) Stridor

Explanation: Anaphylaxis commonly presents with nausea, urticaria (hives), and stridor due to airway constriction. Bradycardia and hypertension are not typical in anaphylaxis.

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

A) Test for the presence of the client’s gag reflex

Explanation: Checking the gag reflex ensures that the client can safely swallow and reduces the risk of aspiration.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm³. Which of the following interventions should the nurse include?

A) Avoid IM injections

Explanation: With a low platelet count, the client is at increased risk for bleeding, so avoiding IM injections is important.

A nurse is preparing to assess the function of the client’s trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

C) Cotton wisps

Explanation: Cotton wisps are used to test the sensory function of the trigeminal nerve.

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety?

D) Disulfiram

Explanation: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is consumed.

A newly admitted client who has major depressive disorder states to the nurse, “I’m a failure, I can’t even cope with the little things anymore.” Which of the following responses should the nurse provide?

C) “Do you feel like you don’t deserve to feel good about yourself?”

Explanation: This response encourages the client to express their feelings, promoting therapeutic communication.

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson’s developmental task for her age group?

B) “I think I have done a good job with my children since they are all independent now.”

Explanation: According to Erikson, generativity versus stagnation is the developmental stage for middle-aged adults, and feeling accomplished with raising independent children reflects success in this stage.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

A) Client’s level of comfort and ability to participate in the interview

Explanation: During the introductory phase, assessing the client’s comfort ensures a smooth and patient-centered interview process.

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

A) Inspection

Explanation: Inspection is the first step in an abdominal assessment before auscultation, palpation, or percussion.

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

D) Gait

Explanation: Inspection is used to observe a client’s gait, as well as other visual signs such as posture and appearance.

Would you like to continue with the next set of questions?

You said:

continue

ChatGPT said:

ChatGPT

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk for which of the following health alterations?

C) Decreased cardiac output

Explanation: Immobility can lead to decreased cardiac output due to reduced venous return and muscle inactivity.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

C) Raise the level of the bed

Explanation: Raising the bed allows the nurse to perform oral care more effectively and helps prevent aspiration.

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client’s medical record?

D) “The client threw the medication on the floor.”

Explanation: Documenting exactly what occurred provides an objective record of the event.

A nurse in a rehabilitation facility is observing an assistive personal (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

A) Locking the brakes on the bed and the wheelchair before moving the client

Explanation: Locking the brakes is essential to prevent movement and ensure the client’s safety during the transfer.

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?

D) “Would you like to talk about how you feel?”

Explanation: This response encourages the client to express their emotions and helps foster open communication.

A nurse is assessing the pH of a client’s gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

B) 2

Explanation: A pH of 2 indicates the acidic environment of the stomach, confirming proper tube placement.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

B) “It modulates the transmission of the pain impulse”

Explanation: TENS works by modulating the transmission of pain signals to the brain.

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following places the client at risk for impaired skin integrity?

B) Faint pedal pulses

Explanation: Faint pedal pulses indicate poor circulation, which increases the risk of impaired skin integrity and pressure injuries.

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply)

B) Dry, brittle hair

D) Spoon-shaped nails

E) Poor wound healing

Explanation: These findings are common in clients with protein-calorie malnutrition due to insufficient intake of essential nutrients.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

A) Sit at the bedside while feeding the client

Explanation: Sitting at the bedside ensures that the nurse can assist the client and monitor for any difficulties during feeding.