ATI RN Med Surg Proctored Exam 22024
04 September 2024ATI RN Med-Surg Proctored Exam 2023 and 2024
A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first?
ANSWER: Initiate airborne precautions. Rationale: Airborne precautions should be initiated immediately if a client presents with symptoms of an airborne disease, such as tuberculosis.
A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. Which of the following findings increases the client’s risk?
ANSWER: History of Crohn’s disease. Rationale: Crohn’s disease is a chronic inflammatory condition that increases the risk of colorectal cancer.
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?
ANSWER: “I can give you additional information about the procedure.” Rationale: This response provides the client with support and further information, allowing them to make an informed decision.
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
ANSWER:
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 the transfusion of the unit of packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: These steps ensure proper administration and monitoring to prevent transfusion reactions.
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
ANSWER: “I should expect less than 25 mL of secretions per day in the drainage devices.” Rationale: This reflects normal postoperative expectations for a mastectomy with a breast expander.
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which Glasgow Coma Scale score should the nurse assign the client?
ANSWER: 5. Rationale: This score is based on the client’s inability to open their eyes, abnormal posturing, and incomprehensible speech.
A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?
ANSWER: “I can have a frozen fruit juice bar for dessert.” Rationale: Frozen fruit juice bars typically do not contain sodium, making them a suitable option for a low-sodium diet.
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 take first?
ANSWER: Instill 0.9% sodium chloride solution into the affected eye. Rationale: Irrigation with normal saline is necessary to remove the chemical and prevent further injury.
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
ANSWER: Stridor. Rationale: Stridor indicates airway obstruction, which is an emergency and requires immediate intervention.
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
ANSWER: Elevated blood glucose. Rationale: Pancreatitis can impair insulin production, leading to hyperglycemia.
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
ANSWER: Urine specific gravity of 1.001. Rationale: A very low urine specific gravity is characteristic of diabetes insipidus due to the large volume of diluted urine.
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
ANSWER: Initiate a continuous IV heparin infusion. Rationale: Anticoagulation therapy with heparin is a primary treatment for pulmonary embolism.
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?
ANSWER: Avoid extremely hot or cold temperatures. Rationale: Extreme temperatures can trigger a sickle cell crisis by causing vasoconstriction or vasodilation, leading to complications.
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?
ANSWER: Insert a large-bore IV catheter. Rationale: Rapid fluid replacement is essential in hypovolemic shock, and a large-bore IV catheter allows for fast fluid administration.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
ANSWER: Palpable thrill. Rationale: A palpable thrill is a normal finding in a functioning arteriovenous graft and indicates proper blood flow.
A nurse is providing discharge teaching to a client who has had a modified radical mastectomy with a breast expander. Which of the following statements by the client indicates understanding of the teaching?
ANSWER: “I should expect less than 25 mL of secretions per day in the drainage devices.” Rationale: Drainage output of less than 25 mL per day is expected after the initial postoperative period.
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Identify the sequence of steps the nurse should follow.
ANSWER:
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 the transfusion of the packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: This sequence ensures proper blood administration and monitoring for transfusion reactions.
A critical care nurse is assessing a client who has a severe head injury. In response to painful stimuli, the client does not open their eyes, displays decerebrate posturing, and makes incomprehensible sounds. Which of the following Glasgow Coma Scale (GCS) scores should the nurse assign the client?
ANSWER: 5 Rationale: The GCS score of 5 is based on the client’s response to painful stimuli, lack of eye-opening, abnormal posturing, and incomprehensible sounds.
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?
ANSWER: Urine specific gravity of 1.001 Rationale: Clients with diabetes insipidus produce large amounts of dilute urine, resulting in a very low urine specific gravity.
A nurse is providing discharge teaching to a client who has heart failure and has been instructed to limit sodium intake to 2 g per day. Which of the following statements by the client indicates understanding of the teaching?
ANSWER: “I can have a frozen fruit juice bar for dessert.” Rationale: Frozen fruit juice bars generally contain little or no sodium, making them suitable for a low-sodium diet.
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?
ANSWER: Instill 0.9% sodium chloride solution into the affected eye. Rationale: Irrigating the eye with normal saline helps to flush out the chemical and minimize damage.
A nurse is assessing a client following extubation from a ventilator. For which of the following findings should the nurse intervene immediately?
ANSWER: Stridor Rationale: Stridor is a sign of airway obstruction, which is a medical emergency requiring immediate intervention.
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
ANSWER: Elevated blood glucose Rationale: Pancreatitis can cause damage to the pancreas, affecting insulin production and leading to elevated blood glucose levels.
A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions should the nurse include in the client’s plan of care?
ANSWER: Initiate a continuous IV heparin infusion. Rationale: Anticoagulation therapy with IV heparin is the treatment of choice for pulmonary embolism to prevent further clot formation.
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?
ANSWER: Avoid extremely hot or cold temperatures. Rationale: Extremes of temperature can trigger a sickle cell crisis by causing vasoconstriction or vasodilation.
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?
ANSWER: Insert a large-bore IV catheter. Rationale: A large-bore IV catheter allows for rapid fluid administration, which is essential in treating hypovolemic shock.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
ANSWER: Palpable thrill. Rationale: A palpable thrill is an expected finding in a functioning arteriovenous graft, indicating proper blood flow.
A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. Which of the following findings should the nurse identify as increasing the client’s risk?
ANSWER: History of Crohn’s disease. Rationale: Chronic inflammatory conditions like Crohn’s disease increase the risk of developing colorectal cancer.
A nurse is assessing a client who has been extubated following a ventilator removal. Which of the following findings requires immediate intervention by the nurse?
ANSWER: Stridor Rationale: Stridor indicates a compromised airway, which requires immediate attention to prevent respiratory distress.
A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?
ANSWER: Hypoactive bowel sounds Rationale: Hypokalemia can cause a decrease in gastrointestinal motility, leading to hypoactive bowel sounds.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?
ANSWER: Check for the type and number of units of blood to administer. Rationale: Ensuring that the correct blood type and number of units are administered is the first step in ensuring a safe transfusion.
A nurse is caring for a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?
ANSWER: “I will monitor my blood pressure while taking this medication.” Rationale: Epoetin alfa can cause hypertension, so it is important for the client to monitor their blood pressure regularly.
A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia?
ANSWER: WBC count 2,000/mm³ Rationale: Pancytopenia refers to a deficiency of all blood cells (red cells, white cells, and platelets), and a low WBC count indicates this condition.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?
ANSWER: “Ginkgo biloba can cause an increased risk for bleeding.” Rationale: Ginkgo biloba can increase the risk of bleeding, especially in clients who are on anticoagulants or have upcoming surgeries.
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
ANSWER: Verify blood compatibility with another nurse. Rationale: Verifying blood compatibility with another nurse ensures that the correct blood is being administered and prevents transfusion reactions.
A nurse is caring for a client who has heart failure and is instructed to limit sodium intake to 2 g per day. Which of the following client statements indicates understanding of the teaching?
ANSWER: “I can have a frozen fruit juice bar for dessert.” Rationale: Frozen fruit juice bars typically contain little or no sodium, making them an appropriate choice for a low-sodium diet.
A nurse is assessing a client who has a suspected stroke. The nurse should place the priority on which of the following findings?
ANSWER: Dysphagia Rationale: Dysphagia, or difficulty swallowing, increases the risk for aspiration, which could lead to further complications.
A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following instructions should the nurse include?
ANSWER: Flex the foot every hour when awake. Rationale: Flexing the foot every hour promotes circulation and helps prevent deep vein thrombosis (DVT) after surgery.
A nurse is caring for a client who has chronic kidney disease and is being treated with dialysis. Which of the following foods should the nurse instruct the client to avoid?
ANSWER: Bananas Rationale: Bananas are high in potassium, which clients with chronic kidney disease must avoid due to the risk of hyperkalemia.
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following laboratory results should the nurse expect?
ANSWER: Urine specific gravity 1.001 Rationale: Diabetes insipidus causes the excretion of large amounts of dilute urine, leading to a low urine specific gravity.
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include in the client’s plan of care?
ANSWER: Initiate a continuous IV heparin infusion. Rationale: Anticoagulation with IV heparin is the primary treatment to prevent further clot formation in pulmonary embolism.
A nurse is assessing a client who has had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect?
ANSWER: Stone fragments in the urine Rationale: After ESWL, clients often pass fragments of kidney stones in their urine.
A nurse is reviewing the medical record of a client who has Crohn’s disease. Which of the following findings should the nurse identify as increasing the client’s risk for colorectal cancer?
ANSWER: History of Crohn’s disease Rationale: Chronic inflammation from Crohn’s disease increases the risk for developing colorectal cancer.
A nurse is caring for a client who has had a mastectomy and tells the nurse, “I’m not sure I want to have the procedure.” Which of the following statements should the nurse make?
ANSWER: “I can give you additional information about the procedure.” Rationale: Providing more information helps the client make an informed decision and reassures them about their options.
A nurse is preparing to administer packed RBCs to a client who is anemic. Identify the correct sequence of steps the nurse should follow.
ANSWER:
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 packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: These steps ensure safe administration and monitoring of blood transfusions to prevent adverse reactions.
A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements should the nurse make?
ANSWER: “You should avoid crossing your legs to prevent dislocation.” Rationale: Clients should avoid crossing their legs after hip surgery to prevent dislocation of the prosthesis.
A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?
ANSWER: Crackles heard on auscultation Rationale: Crackles indicate fluid overload, a potential side effect of mannitol, which should be reported immediately.
A nurse is caring for a client who has an arteriovenous graft for hemodialysis. Which of the following findings indicates adequate circulation of the graft?
ANSWER: Palpable thrill Rationale: A palpable thrill is an expected finding in a functioning arteriovenous graft and confirms adequate blood flow.
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following laboratory results should the nurse expect?
ANSWER: Elevated amylase Rationale: Amylase levels are elevated in acute pancreatitis due to inflammation of the pancreas.
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?
ANSWER: “Avoid extreme temperatures.” Rationale: Extreme temperatures can precipitate a sickle cell crisis by causing vasoconstriction or vasodilation.
A nurse is caring for a client who has heart failure and is instructed to limit sodium intake to 2 g per day. Which of the following client statements indicates understanding of the teaching?
ANSWER: “I will avoid eating canned soup.” Rationale: Canned soups are often high in sodium and should be avoided by clients who are on a low-sodium diet.
A nurse is assessing a client following a thyroidectomy. Which of the following findings is the nurse’s priority?
ANSWER: Stridor Rationale: Stridor is a sign of airway obstruction, which requires immediate intervention.
A nurse is caring for a client who has diabetes insipidus. Which of the following laboratory findings should the nurse expect?
ANSWER: Low urine specific gravity Rationale: Diabetes insipidus causes the excretion of large amounts of dilute urine, resulting in a low urine specific gravity.
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 the procedure.” Which of the following responses should the nurse make?
ANSWER: “I can give you additional information about the procedure.” Rationale: Providing additional information helps the client make an informed decision about their surgery.
A nurse is preparing to administer packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
ANSWER:
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 the transfusion of the packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: Following these steps ensures that the blood transfusion is done safely and the client is monitored for reactions.
A nurse is providing discharge teaching to a client who has a modified radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
ANSWER: “I should expect less than 25 mL of drainage per day from the drainage device.” Rationale: Postoperative drainage of less than 25 mL per day is an expected outcome after a mastectomy with a breast expander.
A nurse is assessing a client following extubation from a ventilator. Which of the following findings requires immediate intervention by the nurse?
ANSWER: Stridor Rationale: Stridor indicates a potential airway obstruction, which is an emergency requiring immediate intervention.
A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take first?
ANSWER: Verify blood compatibility with another nurse. Rationale: Verifying blood compatibility is the most important safety step to prevent transfusion reactions.
A nurse is caring for a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include in the discharge teaching?
ANSWER: Avoid extreme temperatures. Rationale: Extremes of temperature can trigger sickle cell crises by causing vaso-occlusion, which leads to pain and complications.
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
ANSWER: Elevated blood glucose Rationale: Pancreatitis affects the pancreas’s ability to produce insulin, leading to elevated blood glucose levels.
A nurse is planning care for a client who has a pulmonary embolism. Which of the following interventions should the nurse include?
ANSWER: Initiate a continuous IV heparin infusion. Rationale: IV heparin is the treatment of choice for pulmonary embolism to prevent further clot formation.
A nurse is assessing a client following a thyroidectomy. Which of the following findings is the nurse’s priority?
ANSWER: Stridor Rationale: Stridor suggests airway obstruction, which is a medical emergency requiring immediate intervention.
A nurse is providing discharge teaching to a client who has heart failure and is instructed to limit sodium intake to 2 grams per day. Which of the following statements by the client indicates understanding of the teaching?
ANSWER: “I will avoid eating canned soup.” Rationale: Canned soups are often high in sodium and should be avoided on a low-sodium diet.
A nurse is assessing a client who has diabetes insipidus. Which of the following laboratory findings should the nurse expect?
ANSWER: Urine specific gravity of 1.001 Rationale: Clients with diabetes insipidus produce large amounts of dilute urine, resulting in a very low urine specific gravity.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
ANSWER: Palpable thrill Rationale: A palpable thrill is a normal finding that indicates adequate blood flow through the arteriovenous graft.
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the sequence of steps the nurse should follow.
ANSWER:
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 the transfusion of the packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: This step-by-step process ensures the safe administration of blood and reduces the risk of transfusion reactions.
A nurse is caring for a client who has heart failure and is instructed to limit sodium intake to 2 g per day. Which of the following statements by the client indicates understanding of the teaching?
ANSWER: “I will avoid eating canned soup.” Rationale: Canned soups are typically high in sodium and should be avoided on a low-sodium diet.
A nurse is providing discharge teaching to a client who has heart failure. The client is prescribed furosemide and asked to limit sodium intake. Which of the following client statements indicates an understanding of the teaching?
ANSWER: “I should weigh myself daily and report a weight gain of 2 pounds in a day.” Rationale: Daily weight monitoring helps to detect fluid retention, which could indicate worsening heart failure.
A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?
ANSWER: Crackles heard on auscultation Rationale: Crackles suggest fluid overload, which is a possible adverse effect of mannitol and should be reported immediately.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?
ANSWER: Verify the blood type and compatibility with another nurse. Rationale: Verifying blood compatibility is essential to prevent transfusion reactions.
A nurse is assessing a client who has a history of sickle cell anemia. Which of the following findings should the nurse report to the provider immediately?
ANSWER: Swelling of the hands and feet Rationale: Swelling of the hands and feet is a sign of sickle cell crisis, which can lead to serious complications.
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take first?
ANSWER: Verify blood compatibility with another nurse. Rationale: Verifying blood compatibility is essential to ensure the correct blood type is administered and to prevent transfusion reactions.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
ANSWER: Palpable thrill Rationale: A palpable thrill indicates that the graft is functioning properly and has adequate blood flow.
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?
ANSWER: Elevated blood glucose Rationale: Acute pancreatitis can affect insulin production, leading to elevated blood glucose levels.
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?
ANSWER: “Avoid extreme temperatures.” Rationale: Extremes of temperature can trigger a sickle cell crisis by causing vasoconstriction or vasodilation.
A nurse is caring for a client who has heart failure and is instructed to limit sodium intake to 2 grams per day. Which of the following client statements indicates understanding of the teaching?
ANSWER: “I will avoid canned soups and frozen dinners.” Rationale: Canned soups and frozen dinners are often high in sodium, which should be avoided in a low-sodium diet for heart failure management.
A nurse is preparing to administer packed RBCs to a client who has anemia. Identify the correct sequence of steps the nurse should follow.
ANSWER:
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 the transfusion of the packed RBCs.
Remain with the client for the first 15 to 30 minutes. Rationale: Following these steps ensures that the blood transfusion is done safely and the client is monitored for any adverse reactions.
