ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
1….A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is scheduled for an escharotomy. The
client’s spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation.
Rational
An escharotomy is a surgical incision made to release pressure and improve
circulation in a part of the body that has a deep burn and is experiencing excessive
swelling. Burn injuries that encircle a body part, such as an arm or the chest, can
cause swelling and tightness in the affected area, resulting in reduced circulation.
Making surgical incisions into the burned tissue allows the skin to expand, reduces
tightness and pressure, and improves circulation.
2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of
endometriosis. Which of the following findings in the client’s history should the
nurse recognize as consistent with a diagnosis of endometriosis?
Dysmenorrhea that is unresponsive to NSAIDs.
Rational
Endometriosis is a condition in which the type of tissue that lines the uterus
implants in locations outside the uterus. This typically causes pelvic pain
around the time of the menstrual period but can cause pain at other times in
the cycle. The discomfort is often unrelieved by the use of NSAIDs.
3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury
that resulted in paraplegia. After a week on the unit, the nurse notes that the
client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.
Which of the following actions should the nurse take?
Establish a plan of care with the client that sets attainable goals.
Rational
The nurse should develop a plan of care for this client with mutually set goals. This
action invests the client in the rehabilitation process, which encourages feelings of
ownership for it, and sees the goals as more attainable
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
4…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis.
The nurse should expect to find an elevation of which of following values?
Amylase
Rational
Amylase is an enzyme that changes complex sugars into simple sugars that can be
used by the body. It is produced by the pancreas and salivary glands and released
into the mouth, stomach, and intestines to aid in digestion. The amylase level of a
client who has acute pancreatitis usually increases within 12 to 24 hr and can
remain elevated for 2 to 3 days.
5….A nurse is caring for a client who has suspected cholecystitis. The nurse should
expect the client’s urine to appear which of the following colors?
Dark and foamy
Rational
The nurse should expect the client to have dark and foamy urine, which indicates
the kidneys are filtering excess bilirubin from the blood.
6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA)
and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic
tests should the nurse monitor to evaluate the effectiveness of this medication?
Erythrocyte sedimentation rate (ESR)
Rational
Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting
andmonitoringtissueinflammationinclients withRA.Asthediseaseimproves
the ESR decreases.
7….A nurse is providing dietary teaching to a client who has a history of recurring
calcium oxalate kidney stones. Which of the following instructions should the
nurse include in the teaching?
Drink 3 L of fluid every day.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to
dilute the urine and reduce the risk for stone formation.
8….A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following findings should the nurse expect?
Excessive thrombosis and bleeding
Rational
The nurse should expect excessive thrombosis and bleeding of mucous
membranes because both DIC impairs both coagulation and anticoagulation
pathways.
9….A nurse is caring for a middle adult client who has just received the diagnosis
of endometrial cancer. In taking a nursing history, which of the following
manifestations is likely to be reported by this client?
Postmenopausal bleeding
Rational
Endometrial cancer involves cancerous growth of the endometrium (lining of
the uterus). The most common manifestation of endometrial cancer is abnormal
uterine bleeding, including postmenopausal bleeding and bleeding between
normal periods in premenopausal women.
10…A nurse is giving a presentation to a community group about preventing
atherosclerosis. Which of the following should the nurse include as a modifiable
risk factor for this disorder? (Select all that apply.)
Hypercholesterolemia
Hypertension
Obesity
Smoking
11…A nurse is admitting a client who has active tuberculosis to a room on a
medical-surgical unit. Which of the following room assignments should the
nurse make for the client?
A room with air exhaust directly to the outdoor environment
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
A room with air exhaust directly to the outside environment eliminates
contamination of other client-care areas. This type of ventilation system is
referred to as an airborne infection isolation room.
12…A nurse is caring for a client who has Cushing’s syndrome. Which of the
following interventions should the nurse expect to perform? (Select all that apply.)
Assess blood glucose level
Assess for neck vein distention
Incorrect. Monitor for an irregular heart rate
Incorrect. Monitor for postural hypotension
Weigh the client daily
13…A nurse is teaching a client about risk factors for osteoporosis. Which of the
following factors should the nurse include in the teaching? (Select all that apply.)
Sedentary lifestyle
Incorrect. Obesity
Aging
Caffeine intake
Secondhand smoke
Sedentary lifestyle is correct. Immobility depletes bone.
Obesity is incorrect. Women who are obese have a greater capacity for storing
estrogen to help maintain acceptable levels of calcium.
Aging is correct. Women lose bone due to estrogen depletion after menopause.
Caffeine intake is correct. Excessive caffeine intake causes calcium loss in the
urine.
Secondhand smoke is correct. Smoking is a risk factor for osteoporosis, both
active and passive (secondhand) smoking.
14…A nurse is caring for a client who has a history of exposure to TB and
symptoms of night sweats and hemoptysis. Which of the following tests should
the nurse realize is the most reliable to confirm the diagnosis of active pulmonary
TB?
Sputum culture for acid-fast
bacillus Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Although the Mantoux (skin test) and the chest x-ray may be useful screening
tools for TB, the presence of acid-fast bacillus noted in the client’s sputum,
secretions, or tissues is the only method that can actually confirm the diagnosis.
15…A nurse is caring for a client who has emphysema. Which of the following
findings should the nurse expect to assess in this client? (Select all that
apply.)
Dyspnea
Incorrect. Bradycardia
Barrel chest
Clubbing of the fingers
Incorrect. Deep respirations
Rational
Dyspnea is correct.Emphysema is a lung disease involving damage to the alveoli
in which they become weakened and collapse. Dyspnea is seen in clients with
emphysema as the lungs try to increase the amount of oxygen available to the
tissues.
Bradycardia is incorrect. With emphysema, the heart rate will increase as the
heart tries to compensate for less oxygen to the tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the
diaphragm becomes permanently flattened by hyperinflation of the lungs; the
muscles of the rib cage become rigid; and the ribs flare outward. This produces
the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-
oxygen levels. The tips of the fingers enlarge and the nails become extremely
curved from front to back.
Deep respirations is incorrect. Clients with emphysema lose lung elasticity and
have muscle fatigue; consequently, respirations become increasingly shallow.
16…A nurse in an emergency room is caring a the client who sustained partial-
thickness burns to both lower legs, chest, face, and both forearms. Which of the
following is the priority action the nurse should take?
Inspect the mouth for signs of inhalation injuries.
Rational
Since the client sustained burns to the chest and face, there is a possibility that
flames and smoke from the client’s burning clothes could have caused an
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
inhalation injury. The nurse should inspect the mouth and throat for soot and
swelling. Using the airway, breathing, circulation (ABC) priority-setting
framework, is the priority concern at this time
17…A nurse is planning care for a client who is being treated with
chemotherapy and radiation for metastatic breast cancer, and who has
neutropenia. The nurse should include which of the following restrictions inthe
client’s plan of care?
Fresh flowers and potted plants in the room
18…A nurse is preparing dietary instructions for a client who has episodes of
biliary colic from chronic cholecystitis. Which of the following instructions should
the nurse include in the teaching plan?
Avoid foods high in fat.
Rational
The nurse should instruct the client to follow a low-fat diet to decrease episodes
of biliary colic. A client who has chronic cholecystitis has intolerance to fatty
foods
19…A nurse is providing preoperative teaching for a client who is scheduled for a
gastrectomy. Which of the following information regarding prevention of
postoperative complications should the nurse include in in the teaching?
Instruct the client about the use of a sequential compression device.
Rational
The nurse should instruct the client about the use of a sequential compression
device to prevent deep-vein thrombosis, a postoperative complication.
20…A nurse is caring for a middle adult female client who reports that her
menstrual periods have become irregular and she has been having hot flashes.
The nurse should expect the client to have which of the following manifestations
associated with early menopause?
Dryness with intercourse
Rational
Menopause, the cessation of a woman’s menstrual periods, occurs when the
ovaries stop making estrogen. Because of the changes in the vagina, some women
can have dryness, discomfort, or pain during sexual intercourseDocument continues below
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ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
21…During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion
on a client’s chest. The lesion is raised and flesh-colored with pearly white
borders. The nurse should recognize that this finding is suggestive of which of the
following types of skin cancer?
Basal cell carcinoma
Rational
A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent,
pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor
grows, it can undergo central ulceration.
22…A nurse is teaching a group of newly license nurses on effective techniques for
counseling clients about sexually transmitted infections (STIs). Which of the
following statements should the nurse include in the teaching?
Ask about the client’s exposure to any past or present STIs.
Rational
The nurse should assess the client exposure to any past or present STIs and any
treatment taken.
23…A nurse is teaching a client who has hepatitis A about preventing
transmission of the virus. Which of the following strategies should the nurse
include in the teaching?
Practice effective hand hygiene.
Rational
Effective hand hygiene—along with immunization, sewer sanitation, and a safe
water supply—are the most effective strategies for preventing the transmission of
hepatitis A.
24…A nurse is assessing a client who has fluid overload. Which of the following
findings should the nurse expect? (Select all that apply.)
Increased heart rate
Increased blood pressure
Increased respiratory rate
Incorrect. Increase hematocrit
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Incorrect. Increased temperature
Rational
Increased heart rate is correct.The nurse should expect the client who has fluid
volume excess to have tachycardia and increased cardiac contractility in
response to the excess fluid.
Increased blood pressure is correct. The nurse should expect the client who has
fluid volume excess to have increased blood pressure and bounding pulse in
response to the excess fluid.
Increased respiratory rate is correct. The nurse should expect the client who has
fluid volume excess to have increase in respiratory rate and moist crackles heard
in lungs.
Increased hematocrit is incorrect. The nurse should expect the client who has
fluid volume deficit to have an elevated hematocrit because of
hemoconcentration.
Increase temperature is incorrect. The nurse should expect the client who has
fluid volume deficit to have an increase in temperature due to fluid loss.
25…A staff nurse is teaching a client who has Addison’s disease about the disease
process. The client asks the nurse what causes Addison’s disease. Which of the
following responses should the nurse make?
It is caused by the lack of production of aldosterone by the adrenal gland.
Rational
Addison’s disease is caused by a lack of production of the adrenocorticotropic
hormones (cortisol and aldosterone) by the adrenal gland
26…FLAG
A nurse is providing discharge teaching for a client who is postoperative following
a simple mastectomy. The client is to begin outpatient radiation therapy the next
day. Which of the following instructions about maintaining skin integrity should
the nurse include?
Do not apply heat to the area of irradiation.
Rational
This instruction will help the client avoid tissue damage. Radiated tissue becomes
thinner and might lack tissue receptors that would otherwise alert the client to a
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
potential burn injury. When outdoors in sunlight, the client should wear protective
clothing over the area of irradiation.
27…A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test.
Which of the following statements should the nurse include in the teaching?
A CA 125 test is used to monitor a client’s progress during treatment of ovarian
cancer.
Rational
CA 125 tests are useful in monitoring progress during and after treatment of
ovarian cancer
28…A nurse is teaching a client about the seven warning signs of cancer. Which
of the following signs shouldthe nurse include asmanifestations of cancer?
(Select all that apply.)
A non-healing sore
Incorrect. Bloating
Change in bowel pattern
Change in moles
Nagging cough
29…A nurse is monitoring a client who was admitted with a severe burn injury and
is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in
which of the following findings as an indication of adequate fluid replacement?
Heart rate
Rational
When a client’s circulating fluid volume is low, the heart rate increases to maintain
adequate blood pressure. Therefore, the nurse should identify a decrease in heart
rate as in indication of adequate fluid replacement
30…A nurse is caring for a client who has myelosuppression after receiving
chemotherapy. The nurse should monitor the client for which of the following
adverse effects?
Bleeding from the gums
Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Bleeding from the gums is directly related to myelosuppression due to inhibited
bone marrow production of blood cells and platelets.
31…A nurse is providing discharge teaching to a client who has a new
arteriovenous fistula in the right forearm. Which of the following manifestations
should the nurse include in the teaching as a possible indication of venous
insufficiency?
Cold and numb numbness distal to the fistula site
Pallor and numbness distal to the fistula site are possible indicators of venous
insufficiency and should be immediately reported to the provider.
32…A nurse is planning an educational program about basal cell carcinoma. Which
of the following information should the nurse plan to include?
Basal cell carcinoma has a low incidence of metastasis.
Rational
Basal cell carcinoma is a localized lesion that seldom metastasizes.
33…A nurse receives a unit of packed RBCs from a blood bank and notes that the
time is 1130. The nurse should begin the infusion at which of the following
times? As soon as the nurse can prepare the client and the administration set
Rational
The nurse should infuse the blood as soon as possible and complete the
procedure within 4 hr.
34…A nurse is teaching self-management to a client who has hepatitis B. Which
of the following Instructions should the nurse include in the teaching?
Rest frequently throughout the day.
Rational
Limiting activity is usually recommended until the symptoms of hepatitis have
subsided. The nurse should recommend the client rest frequently throughout the
day to reduce the metabolic demands upon the liver and decrease energy
demands.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
35…A nurse is caring for a client who has HIV. Which of the following laboratory
values is the nurse’s priority?
CD4-T-cell count 180 cells/mm3
Rational
A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the
priority for the nurse to report to the provider
36…A nurse is instructing a client how to decrease the nausea associated
with chemotherapy and radiation. Which of the following statements
indicates an understanding of the teaching?
I will eat foods that are served at room temperature.
Rational
The nurse should instruct the client to eat foods served at room temperature or
chilled. Foods served hot may contribute to nausea.
37…A nurse is reviewing discharge instructions with a client following a right
cataract extraction. Which of the following instructions should the nurse include?
Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Rational
The nurse should instruct the client to avoid activities that increase intraocular
pressure. Therefore, the nurse should instruct the client to avoid lifting anything
heavier than 4.5 kg (10 lb) for 1 week following surgery.
38…A nurse is teaching about adverse effects of anastrozole with a client who has
advanced breast cancer and is postmenopausal. Which of the following adverse
effects should the nurse recommend the client report to the provider?
Musculoskeletal pain
Rational
The client who is experiencing musculoskeletal pain should notify the provider.
Musculoskeletal pain is a common adverse effect that affects 50% of clients that
is possibly caused from estrogen deprivation
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
39…A nurse is reviewing the laboratory findings for a client who developed fat
embolism syndrome (FES) following a fracture. Which of the following laboratory
findings should the nurse expect?
Decreased serum calcium level
Rational
A decreased serum calcium level is an expected finding for FES, although the
reason for this finding is unknown.
40…A client is receiving treatment for stage IV ovarian cancer and asks the nurse
to discuss her prognosis. The client plans to have aggressive surgical, radiation,
and chemotherapy treatments. Which of the following prognoses should the
nurse discuss with the client?
Poor
Rational
At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is
the leading cause of death from female reproductive cancers. Survival rates are
low because it is not often discovered until its late stages.
41…A nurse is providing teaching to a client who has had a total abdominal
hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of
the following instructions should the nurse include in the teaching?
Artificial lubrication can be used to treat vaginal itching and dryness.
Rational
The nurse should instruct the client that atrophic vaginal changes occur due to the
loss of estrogen postoperatively and can also cause pain and dryness during sexual
intercourse. Artificial lubricants can reduce the manifestations associated with
diminished mucous production.
42…A nurse at a rehabilitation center is planning care for a client who had a left
hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the
following goals should the nurse include in the client’s rehabilitation program?
Establish the ability to communicate
effectively. Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
A CVA is an interruption of the blood supply to any part of the brain, resulting in
damaged brain tissue. The left hemisphere is usually dominant for language.
Because this client had a left-side CVA, the nurse should anticipate the client will
have some degree of aphasia and will require speech therapy to establish
communication.
43…A nurse is teaching a client about the causes of osteoporosis. The nurse
should include which of the following types of medication therapy as a risk factor
for osteoporosis?
Thyroid hormones
Rational
Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate
bone loss.
44…A nurse is teaching a newly licensed nurse about gynecological examination.
Which of the following information should the nurse include in the teaching?
The urethral orifice is assessed by separating the labia minora.
Rational
The urethral orifice, clitoris, and vaginal orifice are examined for lesions,
inflammation, and discharge by separating the labia minora.
45…FLAG
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which
of the following abnormalities on the client’s EKG should the nurse interpret as a
sign of hypokalemia?
Abnormally prominent U wave
Rational
Although U waves are rare, their presence can be associated with hypokalemia,
hypertension and heart disease. For a client who has hypokalemia, the nurse
should monitor the EKG strip for a flattened T wave, prolonged PR interval,
prominent U wave, or ST depression.
46…A nurse is assessing a client who reports numbness and pain in his right palm,
index finger, and middle finger. The client reports working with a keyboard most of
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
the time while at work. The nurse suspects carpal tunnel syndrome. Which of
the following tests should the nurse request that the client perform?
Hold the wrist at a 90-degree flexion.
Rational
Carpal tunnel syndrome is the compression of the median nerve at the wrist.
The condition is common in people who perform repetitive motions of the hand
and wrist, such as typing. Tapping over the median nerve at the wrist may cause
pain to shoot from the wrist to the hand, andbending the wrist at a 90-degree
flexion will usually result in numbness, tingling, or weakness
47…A nurse is teaching a class about preventive care to clients who are at risk for
acquiring viral hepatitis. Which of the following information should the nurse
include in the presentation?
Avoid foods prepared with tap water.
Rational
To decrease the risk for acquiring viral hepatitis, clients should prepare foods with
purified water.
48…A nurse is providing teaching to a client about the manifestations of uterine
prolapse. Which of the following statements by the client should indicate to the
nurse a need for further teaching?
Feces can be present in the vagina.
Rational
The presence of feces in the vagina is a manifestation of a genital fistula. This
statement indicates a need for further teaching.
49…A nurse is assessing a client who has had staples removed from an abdominal
wound postoperatively. The nurse notes separation of the wound edges with
copious light-brown serous drainage. Which of the following actions should the
nurse perform first?
Cover the wound with a moist, sterile gauze dressing.
Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
The client’s wound has dehisced, or opened along the suture line, and is now
draining. The primary clinical objective in managing a dehisced wound is to keep
it clean and moist, and manage any exudate. The nurse’s priority action therefore
is to cover the wound with a moist, sterile, saline-soaked gauze dressing
50…A nurse is assessing a client’s wound dressing, and observes a watery red
drainage. The nurse should document this drainage as which of the
following? Serosanguineous
Rational
Watery red drainage should be documented as serosanguineous.
51…A nurse is providing instructions for a 52-year-old client who is scheduled for a
colonoscopy. The client reports that he has not had the procedure before and is
very anxious about feeling pain during the procedure. Which of the following
responses by the nurse is appropriate?
Before the examination, your provider will give you a sedative that will make
you sleepy.
Rational
This therapeutic response appropriately addresses the client’s concerns. The
client is seeking information and this response provides the client with accurate
information. It can also lead to further discussion about the procedure.
52…A nurse is teaching a client about preventing osteoporosis. Which of the
following statements by the client indicates a need for further teaching?
I will reduce my intake of vitamin K-rich foods.
Rational
Vitamin K is necessary for bone health. The nurse should instruct the client to
increase her intake of vitamin K-rich foods—such as green, leafy vegetables—to
promote bone health
53…A nurse is selecting a qualified staff member to double check a blood label
with a client ID bracelet prior to infusing a unit of blood. The nurse should
identify that which of the following persons is qualified?
Oncology nurse
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The nurse should ask another nurse or a provider to double check the blood label
and client ID prior to an infusion.
54…A nurse is caring for a client who is scheduled to have a magnetic resonance
imaging (MRI) scan. The client asks the nurse what to expect during the
procedure. Which of the following statements should the nurse make?
An MRI scan is very noisy, and you will be allowed to wear earplugs while in the
scanner.
Rational
The nurse should instruct the client that many clients report being disconcerted
by the loud thumping and humming noises produced by the scanner, and for that
reason, earplugs are offered to reduce the discomfort
55…A nurse is planning care for a client who has end-stage cirrhosis of the liver
with encephalopathy. Which of the following interventions should the nurse plan
to implement to decrease the client’s ammonia level?
Reduce the client’s intake of protein.
Rational
Ammonia is formed in the gastrointestinal tract by the action of bacteria on
protein. Limiting dietary protein intake can assist with decreasing the
client’s ammonialevel. Protein is necessary for healing, so strict limitation
of dietary protein is not recommended.
56…A nurse is caring for a client who is unconscious and has a breathing pattern
characterized by alternating periods of hyperventilation and apnea. The nurse
should document that the client has which of the following respiratory
alterations?
Cheyne-Stokes respirations
Rational
Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the
point of hyperventilation) and decrease (to the point of apnea) in the rate and
depth of respiration. CSR are common respiratory alterations seen in clients who
are unconscious, comatose, or moribund (approaching death).
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
57…A nurse is caring for a client scheduled to receive external radiation to the
neck for cancer of the larynx. During a pre-treatment exam, the nurse explains
to the client that the most likely side effect would be
Dysphagia.
Rational
Radiation therapy does not hurt while it is being given. But the side effects that
people may get from radiation therapy can cause pain or discomfort. Only the
area of treatment is affected by the radiation, so dysphagia (trouble swallowing)
would be an expected side effect. Other possible side effects include
hoarseness, xerostomia (dry mouth), loss of taste, and skin redness
58…A nurse is caring for a client who is 1-day postoperative following a left lower
lobectomy and has a chest tube in place. When assessing the client’s three-
chamber drainage system, the nurse notes that there is no bubbling in the
suction control chamber. Which of the following actions should the nurse take?
Verify that the suction regulator is on and check the tubing for leaks.
Rational
A lack of bubbling may indicate that either the suction regulator is turned off or
that there is a leak in the tubing.
59…A nurse is caring for a client who has a severe gangrenous infection of the
right lower extremity. The nurse should plan preoperative teaching based on the
possibility of which of the following amputation procedures?
Your pain will gradually become less severe.
Rational
Phantom leg pain usually diminishes over time, and often is intermittent in
response to a trigger.
60…A female middle adult client tells a nurse that she tested positive for a
mutant BRCA1 gene. The nurse should recognize that the client is at an increased
risk for which of the following situations?
Developing breast cancer
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The BRCA1 gene is used to determine the probability of a client developing breast
cancer. BRCA1 genetic testing is used for women who have a strong family history
of breast cancer
61…A nurse is planning a teaching session about hysterosalpingography for a
client who has a diagnosis of infertility. The nurse should include which of the
following information in the teaching plan?
The client might experience shoulder pain following the procedure.
Rational
Shoulder pain can occur due to phrenic nerve irritation cause by the contrast
media.
62…A nurse is caring for a client who is experiencing menopausal symptoms and
asks the nurse about menopausal hormone therapy (HT). The nurse should inform
the client that HT is not recommended due to which of the following findings in
the client’s medical history?
History of breast cancer
Rational
Women with a history of breast cancer should be counseled against using HT.
63…A nurse is planning care for a client who has immunosuppression following
chemotherapy.Which of the following interventions should the nurse include
in the plan of care?
Limit the number of health care workers entering the room.
Rational
The nurse should limit the number of health care workers entering the client’s
room to prevent possible overexposure to microorganisms that can lead to an
infection.
64…A nurse is preparing a client who has AIDS for discharge. Which of the
following statements should the nurse include in the discharge instructions?
Prevent the spread of infection with good household cleaning practices.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The client should follow standard precautions and use a 1:10 solution of bleach to
disinfect areas that come into contact with blood and body fluids.
65…A nurse is caring for four hospitalized clients. Which of the following clients
should the nurse identify as being at risk for fluid volume deficit?
The client who has gastroenteritis and is febrile.
Rational
This client has two risk factors for the development of fluid volume deficit, or
dehydration. Gastroenteritis is characterized by diarrhea and may also be
associated with vomiting, so it can be a significant source of fluid loss. The client
who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic
rate, further putting the client at increased risk for dehydration. Consequently, this
is the client at greatest risk for fluid volume deficit.
66…A nurse is caring for a client with a tracheostomy. The client’s partner has
been taught to perform suctioning. Which of the following actions by the partner
should indicate to the nurse a readiness for the client’s discharge?
Performing the procedure independently
Rational
The nurse should recognize that the client is ready for discharge when the spouse
demonstrates an ability to perform the procedure that will need to be performed
independently at home
67…A nurse is caring for a client who is receiving cisplatin to treat bladder cancer.
After several treatments, the client reports fatigue. Which of the following actions
should the nurse take?
Check the results of the client’s most recent CBC
Rational
The client might have anemia as a result of myelosuppression (bone marrow
suppression) from the chemotherapy. If so, she might require treatment for the
anemia (transfusion, medication) and the provider might have to delay further
chemotherapy until her blood counts are higher.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
68…A nurse is teaching a client who has septic shock about the development of
disseminated intravascular coagulation (DIC). Which of the following statements
should the nurse make?
DIC is caused by abnormal coagulation involving fibrinogen.
Rational
DIC is caused by abnormal coagulation involving the formation of multiple small
clots that consume clotting factors and fibrinogen faster than the body can
produce them, increasing the risk for hemorrhage.
69…A nurse is caring for a client who is HIV positive and is one day postoperative
following an appendectomy. The nurse should wear a gown as personal
protective equipment when taking which of the following actions?
Completing a dressing change
Rational
Standard precautions require personal protective equipment when there is a risk
of contact with body fluids. A dressing change does present a risk for coming
into contact with body fluids
70…A nurse in a clinic is teaching information about cervical polyps with a
client who has a new diagnosis. Which of the following information should the
nurse include in the teaching?
Postcoital bleeding may occur.
Rational
The client may experience postcoital bleeding, because the polyps are soft, fragile,
and bleed when touched.
71…A nurse is planning a presentation about HIV for a church-based group.
Which of the following information about HIV transmission should the nurse
include?
It is primarily transmitted through direct contact with infected body fluids.
Rational
The nurse should include in the teaching that HIV is transmitted through direct
contact with infected blood, seminal fluid, vaginal secretions, amniotic fluid,
breast milk and other body fluids
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
72…A nurse is preparing a client for a radiation treatment who is postoperative
following a mastectomy. The nurse should inform the client to expect which of the
following adverse effects from the treatment?
Fatigue
Rational
The nurse should inform the client to expect fatigue with her radiation treatment.
Fatigue occurs regardless of the radiation target site.
73…A nurse is caring for a client who has had a spinal cord injury at the level of
the T2-T3 vertebrae. When planning care, the nurse should anticipate which of
the following types of disability?
Paraplegia
Rational
Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.
74…A nurse is caring for a client who recently had surgery for insertion of a
permanent pacemaker. Which of the following prescriptions should the nurse
clarify?
MRI of the chest
Rational
A permanent pacemaker is a contraindication for MRI of the chest. The magnets in
the machine can create electromagnetic interference and cause the pacemaker to
malfunction.
75… A nurse is reviewing laboratory values for a client who has systemic lupus
erythematous (SLE). Which of the following values should give the nurse the best
indication of the client’s renal function?
Serum creatinine
Rational
A renal function disorder reduces the excretion of creatinine, resulting in
increased levels of blood creatinine. Creatinine is a specific and sensitive indicator
of renal function.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
76…A nurse is teaching a client about risk factors for osteoarthritis. Which of the
following factors should the nurse include in the teaching? (Select all that apply.)
Incorrect. Bacteria
Incorrect. Diuretics
Aging
Obesity
Smoking
Bacteria is incorrect. Bacterial infections can lead to infectious arthritis, which
does not cause irreversible damage to joints. Infection is not a risk factor for
osteoarthritis.
Diuretics is incorrect. Diuretic therapy is a possible risk factor for gout, but not for
osteoarthritis.
Aging is correct. Aging is a risk factor for osteoarthritis, as the joints bear the load
of the body’s weight over time.
Obesity is correct. Obesity is a risk factor for osteoarthritis, as it increases the load
of the body’s weight over time.
Smoking is correct. Smoking is a risk factor for osteoarthritis, as smoking
predisposes people to the loss of cartilage in the knees.
77… A nurse is admitting a client who has acute pancreatitis. Which of the
following provider prescriptions should the nurse anticipate?
Pantoprazole 80 mg IV bolus twice daily
Rational
The nurse should anticipate a provider’s prescription for a proton pump inhibitor
to decrease gastric acid production, which ultimately decrease pancreatic
secretions
78… A nurse is caring for a client who is 2 hr postoperative following a
transurethral resection of the prostate (TURP) gland. Which of the following
assessments should the nurse view to be an indication of a postoperative
complication?
Output of burgundy colored
urine Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Output of burgundy colored urine may indicate venous bleeding, a potential
complication following a TURP. Should this occur, the nurse should inform the
provider and anticipate an order for increased CBI rate or manual irrigation of the
catheter.
79…A nurse is reviewing the arterial blood gas values of a client who has chronic
kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
Rational
The nurse should expect a client who has renal failure to have metabolic acidosis,
which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2.
Expected reference ranges for these laboratory values are as follows: pH 7.35 to
7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.
80…A nurse is caring for a client who was admitted with bleeding esophageal
varices and has an esophagogastric balloon tamponade with a Sengstaken-
Blakemore tube to control the bleeding. Which of the following actions should the
nurse take?
Provide frequent oral and nares care.
Rational
A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If
the client is alert, the nurse should encourage the client to spit saliva into a tissue
or basin. If the client is not alert, gentle suctioning of the oral cavity and nares
might be required to remove secretions.
81…A nurse is providing teaching to a client who is postoperative following
coronary artery bypass graft (CABG) surgery and is receiving opioid medications
to manage discomfort. Aside from managing pain, which of the following desired
effects of medications should the nurse identify as most important for the client’s
recovery?
It facilitates the client’s deep breathing
82… A nurse is presenting a community-based program about HIV and AIDS. A
client asks the nurse to describe the initial symptoms experienced with HIV
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
infection. Which of the following manifestations should the nurse include in the
explanation of initial symptoms?
Flu-like symptoms and night sweats
Rational
The nurse should explain that the initial symptoms may include flu-like symptoms
and night sweats in category A of HIV infection.
83… A nurse is implementing a plan of care for a client who has AIDS with
recurring pneumonia. Which of the following actions should the nurse take?
Obtain a sputum culture
Rational
The nurse should obtain a sputum culture to determine which antibiotic is needed
for the organism that is causing the pneumonia
84…A nurse is caring for a client who reports a new onset of severe chest pain.
Which of the following actions should the nurse take to determine if the client is
experiencing a myocardial infarction?
Perform a 12-lead ECG
Rational
The nurse should perform a 12-lead ECG when a client complains of chest pain to
determine if the client is experiencing a myocardial infarction.
85… A nurse is caring for a client who has advanced lung cancer. The client’s
provider has recommended hospice services for the client. Which of the following
statements by the client indicates a correct understanding of hospice care?
I should expect the hospice team to help me manage my dyspnea.
Rational
Dyspnea is a manifestation of terminal lung cancer. The primary purpose of
hospice care is to provide relief of symptoms related to a terminal illness.
86…A nurse is establishing health promotion goals for a female client who
smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following
goals should the nurse include?
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
The client will walk for 30 min 5 days a week.
Rational
CDC recommendations include engaging in a moderate exercise, such as
walking, for a total of 150 min each week.
87…A nurse is caring for a client who develops a ventricular fibrillation rhythm.
The client is unresponsive, pulseless, and apneic. Which of the following actions
is the nurse’s priority?
Defibrillation
Rational
The greatest risk to the client is death from a lack of cardiac output. Ventricular
fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and
there is no atrial activity. Defibrillation is essential to resolve ventricular
fibrillation promptly and convert the rhythm to restore cardiac output. The nurse
should follow defibrillation with cardiopulmonary resuscitation and repeated
defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable
rhythm.
88…A nurse in a cardiac care unit is caring for a client with acute right-sided heart
failure. Which of the following findings should the nurse expect?
Elevated central venous pressure (CVP).
Rational
CVP is a measurement of the pressure in the right atria or ventricle at the end of
diastole. An elevated CVP is indicative of heart failure
89…A nurse is reviewing the arterial blood gas (ABG) results of a client who the
provider suspects has metabolic acidosis. Which of the following results should
the nurse expect to see?
pH below 7.35
Rational
With acidosis, the pH is below 7.35. However, the pH alone does not indicate
whether the problem is metabolic or respiratory. A pH above 7.45 indicates
alkalosis.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
90…A nurse is teaching a client who has hypertension and a new prescription for
atenolol. Which of the following findings should the nurse include as adverse
effects of this medication?
Bradycardia
Rational
Atenolol is a beta-blocker, which slows the heart rate. The nurse should instruct
the client to monitor his pulse rate and report bradycardia.
91…While assessing a client who is receiving continuous IV therapy via his left
forearm, a nurse notes that the site is red, swollen, and painful and that the
surrounding tissues are hard. Which of the following actions should the nurse take
first?
Discontinue the existing IV line
Rational
The greatest risk to the client is injury from the IV infiltration damaging soft
tissues surrounding the catheter. Therefore, the first action the nurse should take
is to discontinue the existing IV line.
92…A nurse in an emergency department is caring for a client who reports
substernal chest pain and dyspnea. The client is vomiting and is diaphoretic.
Which of the following laboratory tests are used to diagnose a myocardial
infarction? (Select all that apply.)
Troponin I
Troponin T
Incorrect. Plasma low-density lipoproteins
CPK
Myoglobin
93…A nurse is caring for a client who has a chest tube connected to a closed
drainage system and needs to be transported to the x-ray department. Which of
the following actions should the nurse take?
Keep the drainage system below the level of the client’s chest at all times.
Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
During transport, the drainage system should be kept below the level of the
client’s chest to prevent air and drainage fluid from re-entering the thoracic
cavity
94…A nurse is caring for a client who has a three-chamber closed chest tube
system. Which of the following actions should the nurse take after noticing a rise
in the water seal chamber with client inspiration?
Continue to monitor the client.
Rational
The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls
during exhalation. This is a process called tidaling. An absence of tidaling might
indicate a fully expanded lung or an obstruction in the chest tube.
95…A nurse is assessing a client’s wound dressing, and observes a watery red
drainage. The nurse should document this drainage as which of the
following? Serosanguineous
96…A nurse is teaching a client about snacks that are appropriate on a low-fat,
low-sodium, and low-colesterol diet. Which of the following food choices by
the client indicates the need for further teaching?
A slice of cheese
Rational
The client should limit the intake of cheese due to high levels of fat and sodium.
97…A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and
initiates cardiac monitoring. Which of the following findings should the nurse
expect during the initial assessment?
Lethargy
Rational
A serum calcium level of 12.3 mg/dL is above the expected reference range. The
nurse should monitor the client for lethargy, generalized weakness, and confusion.
98…A nurse is preparing to initiate a transfusion of packed RBC for a client
who has anemia. Which of the following actions should the plan to nurse
take?
Check the client’s vital signs every hour during the transfusion.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The nurse should check the client’s vital signs every 15 min at the start of the
transfusion, then every 1 hr to monitor for a transfusion reaction.
99…A nurse is planning to teach a client about a lowpotassium diet. Which of the
following foods should the nurse instruct the client to avoid? (Select all that
apply.)
Incorrect. Butter
Incorrect. Poultry
Correct. Yogurt
Incorrect. Frozen vegetables
Correct. Orange juice
100..A nurse is reviewing the laboratory results of a client who has a pressure
ulcer. The nurse should identify an elevation in which of the following laboratory
values as an indication that the client has developed an infection?
WBC count
Rational
An elevation in the WBC count (leukocytosis) indicates that the client’s immune
system is defending him against the pathogens causing an infection.
101..A nurse is caring for a client who has a cardiopulmonary arrest. The nurse
anticipates the emergency response team will administer which of the following
medications if the client’s restored rhythm is symptomatic bradycardia?
Atropine
Rational
The team administers atropine during CPR if the client has symptomatic
bradycardia, or is hemodynamically unstable.
Epinephrine
The team administers epinephrine during cardiopulmonary resuscitation (CPR) to
clients who have asystole or pulseless electrical activity.
Magnesium
The team administers magnesium during CPR for clients who have torsade de
pointes, which is a specific type of ventricular tachycardia.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Sodium bicarbonate
The team administers sodium bicarbonate to correct metabolic acidosis that does
not improve with CPR.
102..A nurse is developing a plan of care for a client who is postoperative. Which
of the following interventions should the nurse include in the plan to prevent
pulmonary complications?
Encourage the use of an incentive spirometer
Rational
Incentive spirometry expands the lungs and promotes gas exchange after surgery
which can help prevent pulmonary complications.
103..A nurse is planning care for a client who is being treated with
chemotherapy and radiation for metastatic breast cancer, and who has
neutropenia.Thenurseshould include which of the following restrictions in the
client’s plan of care?
Fresh flowers and potted plants in the room
Rational
Clients who are receiving chemotherapy and radiation therapy are likely to
become immunocompromised as a result of neutropenia, a decreased white
blood cell (WBC) count. Because micro-organisms are likely to be present on fresh
flowers and plants, immunocompromised clients are instructed not to accept
such gifts into the room. In addition, the client is instructed to eat only thoroughly
cooked meats and thoroughly washed fruits and vegetables.
Immunocompromised clients are more susceptible to infection and illness
from food-borne bacteria than other clients.
104..A nurse is caring for a client who has heart failure and a new prescription for
furosemide. For which of the following adverse effects should the nurse monitor?
Hypokalemia
Rational
Hypokalemia is an adverse effect of furosemide
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
105..A nurse is caring for a client who has a postoperative ileus and an NG tube
that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte
imbalances should the nurse monitor the client for?
Decreased potassium level
Rational
Hypokalemia is an electrolyte imbalance in which the serum potassium level is
less than 3.5 mEq/L. Hypokalemia may be the result of diuretic use, diarrhea,
vomiting, and prolonged nasogastric suctioning
106.. A nurse is caring for a client who has hypertension and develops epistaxis.
Which of the following actions should the nurse take? (Select all that apply.)
Apply pressure to the nares.
Place ice to the bridge of the client’s nose.
Incorrect. Instruct the client to blow his
nose. Incorrect. Tilt the client’s head
backward Move the client into high-Fowler’s
position.
Rational
Apply pressure to the nares is correct. Applying direct pressure to the lateral
aspects of the nose helps to clot the blood. The nurse should apply firm and
consistent pressure for several minutes until coagulation occurs.
Place ice to the bridge of the client’s nose is correct. Placing an ice pack on the
nose causes the blood vessels to vasoconstrict, which decreases bleeding. The
nurse should use a barrier, such as a wash cloth, to avoid skin damage from the
direct application of ice to the skin. Ice packs should not be left on the skin for
longer than 20 min.
Instruct the client to blow his nose is incorrect. The nurse should instruct the
client to avoid blowing his nose for 24 hr as this can cause dislodgement of clots.
The nurse should also discourage coughing, straining, or sneezing as these
activities can also cause the blood vessels to weaken, which can trigger
rebleeding.
Tilt the client’s head backward is incorrect. The nurse should tilt the client’s body
and head forward to decrease the risk for aspiration and swallowing of blood.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Move the client into high-Fowler’s position is correct. Sitting upright facilitates
breathing and decreases the risk for aspiration.
107..A nurse is reviewing the laboratory values of a client who had a myocardial
infarction 3 hr ago. The nurse should expect which of the following laboratory
values to be elevated?
Troponin I
108..A nurse is performing an ECG on a client who is experiencing chest pain.
Which of the following statements should the nurse make?
I will need to apply electrodes to your chest and extremities.
Rational
The nurse should inform the client that she will apply small electrodes to the
client’s chest and extremities before conducting the test. These electrodes
transmit electrical current and allow for the recording of the heart’s electrical
activity
109..A nurse is preparing to administer potassium chloride (KCL) to a client who is
receiving diuretic therapy. The nurse reviews the client’s serum potassium level
results and discovers the client’s potassium level is 3.2 mEq/L. Which of the
following actions should the nurse take?
Give the ordered KCL as prescribed.
Rational
The client’s serum potassium level is below the recommended reference range.
The nurse should administer the KCL as prescribed.
110.. A nurse is completing discharge teaching with a client following arthroscopic
knee surgery. Which of the following instructions should the nurse include in the
teaching?
Apply ice to the affected area.
Rational
Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems
inside a joint. Applying ice to the affected area in the immediate postoperative
period (first 24 hr) reduces pain and swelling.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
111..A nurse is caring for a client who has pericarditis and reports feeling a new
onset of palpitations and shortness of breath. Which of the following assessments
should indicate to the nurse that the client may have developed atrial fibrillation?
Different apical and radial pulses.
Rational
Atrial fibrillation is rapid, disorganized electrical activity of the heart in which the
atrium depolarizes too quickly and sends erratic impulses to the ventricles. The
presence of a pulse deficit between the apical and radial pulses is an indication of
atrial fibrillation. The nurse should assess further by obtaining an ECG or
telemetry reading
112..A client is planning to perform nasotracheal suction for a client who has
COPD and an artificial airway. Which of the following actions should the
nurse take?
Preoxygenate the client with 100% oxygen for up to 3 min.
Rational
To prevent hypoxemia, the nurse should preoxygenate the client with 100%
oxygen for 30 seconds to 3 min prior to suctioning.
113..A nurse is caring for a client who has a new diagnosis of essential
hypertension. The nurse should monitor the client for which of the following
findings that is consistent with this diagnosis?
Vertigo
Rational
The nurse should monitor the client for findings such as vertigo, headache, facial
flushing, and fainting. These manifestations are consistent with a new diagnosis
of essential hypertension.
114..A nurse in an urgent care center is caring for a client who is having an acute
asthma exacerbation. Which of the following actions is the nurse’s highest
priority?
Administering a nebulized beta-adrenergic
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
The greatest risk to the client’s safety is airway obstruction. Beta-adrenergic
medications act as bronchodilators. They provide prompt relief of airflow
obstruction by relaxing bronchiolar smooth muscle and are the initial priority
intervention when a client has an acute asthma exacerbation.
115..The nurse is caring for a client who has heart failure and a history of asthma.
The nurse reviews the provider’s orders and recognizes that clarification is needed
for which of the following medications?
Carvedilol
Rational
Medications that block beta-2 receptors, such as carvedilol, are contraindicated in
clients with asthma.
116.. A nurse is caring for a client who the provider suspects might have
pernicious anemia. The nurse should expect the provider to prescribe which of
the following diagnostic tests?
Schilling test
Rational
The Schilling test helps determine the cause of vitamin B12 deficiency, which leads
to pernicious anemia.
117..A nurse is teaching a client who has been taking prednisone to treat
asthma and has a new prescription to discontinue the medication. The nurse
should explain to the client to reduce the dose gradually to prevent which of the
following adverse effects?
Adrenocortical insufficiency
Rational
Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone
produced by the adrenal glands. It relieves inflammation and is used to treat
certain forms of arthritis, severe allergies, autoimmune disorders, and asthma.
Administration of glucocorticoids can suppress production of glucocorticoids, and
an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
118..A nurse is providing teaching for a client who has hypertension and a
prescription change from metoprolol to metoprolol/hydrochlorothiazide. Which of
the following statements by the client indicates an understanding of the teaching?
With the new medication, I should experience fewer side effects.
Rational
The client has stated an understanding of the purpose of the addition of the
hydrochlorothiazide (HCTZ) to the metoprolol dosage. When used in
combination with thiazide diuretics, a lower dose of the beta-blocker can be
used. The benefit is there are fewer side effects when beta-blockers (and other
antihypertensives) are used in lower dosages
119..A client is teaching a client who has a new prescription for
hydrochlorothiazide for management of hypertension. Which of the following
instructions should the nurse include?
Monitor for leg cramps.
Rational
Hydrochlorothiazide can cause hypokalemia. The client should monitor for
manifestations of hypokalemia, such as fatigue, tachycardia, leg cramps, and
muscle weakness.
120..A nurse is providing teaching to a client who has hypertension and a new
prescription for hydrochlorothiazide. Which of the following instructions should
the nurse provide?
Take the medication early in the day.
Rational
The nurse should instruct the client to take hydrochlorothiazide early in the day to
avoid nocturia.
121..A nurse in a provider’s office is reviewing the laboratory results of a client
who takes furosemide for hypertension. The nurse notes that the client’s
potassium level is 3.3 mEq/L. The nurse should monitor the client for which of
the following complications?
Cardiac dysrhythmias
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
This client’s potassium level is below the expected reference range.
Hypokalemia can cause a numberof cardiac effectsincluding flattened Twaves,
prominent U waves, and S-T depression.
122..A nurse is providing teaching about a heart healthy diet to a group of clients
with hypertension. Which of the following statements by one of the clients
indicates a need for further teaching?
I may eat 10 ounces of lean protein each day
Rational
Lean meats should be limited to 5 to 6 oz per day. This statement by a client
requires additional teaching.
123..A nurse on a medical-surgical unit is performing an admission assessment of
a client who has COPD with emphysema. The client reports that he has a frequent
productive cough and is short of breath. The nurse should anticipate which of the
following assessment findings for this client?
Increased anteroposterior diameter of the chest
Rational
The nurse should anticipate an increased anteroposterior diameter of the chest
(barrel chest) because of chronic hyperinflation of the lungs
124..A nurse is evaluating teaching on a client who has a new prescription for
montelukast to treat asthma. Which of the following statements by the client
indicates an understanding of the teaching?
I’ll take this medication once a day in the evening.
Rational
Montelukast, a leukotriene modifier, is used to prevent asthma exacerbations. The
client should take it on a daily basis once a day in the evening
125..A nurse is caring for a client who has asthma and is taking fluticasone. The
nurse should monitor the client for which of the following adverse effects?
Oral candidiasis
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Rational
Fluticasone can cause oral candidiasis, or thrush; therefore, the client should rinse
her mouth with water
126..A nurse is providing discharge teaching to a client who has asthma and new
prescriptions for cromolyn and albuterol, both by nebulizer. Which of the
following statements by the client indicates an understanding of the teaching?
I will be sure to take the albuterol before taking the cromolyn.
Rational
The client should always use the bronchodilator (albuterol) prior to using the
leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways
to be opened, ensuring that the maximum dose of medication will get to the
client’s lungs.
127..A nurse is discharging a child who has sickle cell anemia after an acute crisis
episode. Which of the following instructions should the nurse include in the
teaching?
Offer fluids to your child multiple times every day
Rational
Preventing dehydration is an important step in preventing a sickle cell crisis.
The nurseshouldprovidetheparentswithaspecificfluidgoalforthechildto
reach each day
128..A nurse is monitoring a client who is receiving a blood transfusion. Which
of the following findings indicates an allergic transfusion reaction?
Generalized urticaria.
Rational
The nurse should recognize urticaria asan indicator of anallergic transfusion
reaction. Other clinical manifestations include itching and signs of
anaphylaxis with bronchospasm.
129..A nurse is collaborating on care for a client who has COPD. Which of
the following tasks should the nurse recommend be referred to an
occupational therapist for assistance?
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Instructing how to use kitchen tools to prepare a meal
Rational
As a member of the interdisciplinary team, the occupational therapist works with
the client todevelop fine motor skills and coordination, such as improving hand
strength and hand movements. The occupational therapist focuses on self-
management of ADLs, such as skills needed for eating, hygiene, and dressing.
Occupational therapists also can teach clients to perform other independent living
skills, such as cooking and shopping
130..A nurse is assessing a client for hypoxemia during an asthma attack. Which
of the following manifestations should the nurse expect?
Agitation
Rational
The nurse should expect agitation due to neurological changes from poor oxygen
exchange.
131.. A nurse is planning to perform a blood transfusion for a client. Which of the
following actions should the nurse plan to take? (Select all that apply.)
Incorrect. Prime the blood tubing with dextrose 5% in water.
Incorrect. Transfuse the blood product within 5 hr after removing it from
refrigeration.
Check the expiration date of the blood product with a second nurse.
132..A nurse is providing discharge teaching to a client who has asthma and a
new prescriptionforfluticasone/salmeterol.Forwhichofthefollowingadverse
effects should the nurse instruct the client to report to the provider?
White coating in the mouth
Rational
Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2
adrenergic agonist combination inhalation medication that is used for daily
management of asthma. It is not a rescue medication. An adverse effect of the
medication is oropharyngeal candidiasis. The nurse should instruct the client to
Check vital signs before
transfusion. Insert an IV with a
19-
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
gargle after each use, use a spacer to reduce the amount of drug in the mouth and
throat, and report any white patches inside the mouth or on the tongue to the
provider
133…A nurse is monitoring a client who has a chest tube in place connected
to wallsuctionduetoaright-sidedpneumothorax.Theclientcomplainsof
chest burning. Which of the following actions should the nurse take?
Reposition the client.
Rational
The nurse repositioning the client is an appropriate action to relieve chest
burning from the chest tube.
134..A nurse is teaching a middle-age client about hypertension. Which of
the following information should the nurse include in the teaching?
Diuretics are the first type of medication to control hypertension.
Rational
The nurse should include in the teaching that diuretic medication is the first type
of medication to control hypertension, by decreasing blood volume and lowering
blood pressure.
135.. The nurse is caring for a postoperative client who has a chest tube
connected to suction and a water seal drainage system. Which of the following
indicates to the nurse that the chest tube is functioning properly?
Fluctuation of the fluid level within the water seal chamber
Rational
Fluctuation of fluid within the water seal chamber occurs with inspiration and
expiration until the client’s lungs have re-expanded or the system is occluded.
136.. A nurse is assessing a client who is 1 day postoperative following a
lobectomy and has a chest tube drainage system in place. Which of the
following findings by the nurse indicates a need for intervention?
Development of subcutaneous
emphysema Rational
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
Subcutaneous emphysema is an indication that air is trapped in and under the
skin, which be the result of a pneumothorax and should be reported to the
provider.
137.. A nurse is caring for a client who had a stroke involving the left cerebral
hemisphere. The nurse should monitor for which of the following findings?
Impaired sense of humor
Rational
A client who had a stroke involving the left cerebral hemisphere is likely to have
language deficits, which include difficult using or comprehending language and
difficulty writing. The nurse should expect a client who had a stroke involving the
right cerebral hemisphere to have an impaired sense of humor.
138..A nurse is caring for a client who has a T-4 spinal cord injury. Which of the
following client findings should the nurse identify as an indication the client is
at risk for experiencing autonomic dysreflexia?
The client’s bladder becomes distended.
Rational
Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with
a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens
when there is an irritation, pain, or stimulus to the nervous system below the
level of injury. There are many kinds of stimulation that can precipitate
autonomic dysreflexia. For example, catheter changes, a distended bladder or
bowel, enemas, and sudden position changes. Manifestations include elevated
blood pressure, severe headache, and flushed face.
139.. A nurse is caring for a client who is receiving cisplatin to treat bladder
cancer. After several treatments, the client reports fatigue. Which of the following
actions should the nurse take?
Check the results of the client’s most recent CBC.
Rational
The client might have anemia as a result of myelosuppression (bone marrow
suppression) from the chemotherapy. If so, she might require treatment for the
anemia (transfusion, medication) and the provider might have to delay further
chemotherapy until her blood counts are higher.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
140.. A nurse is teaching the family of a client who is receiving treatment for a
spinal cord injury with a halo fixation device. Which of the following statements
should the nurse make?
The purpose of this device is to immobilize the cervical spine.
Rational
A client who has an injury to the cervical spine can have a halo fixation device to
provide immobilization of the head and neck for a period of 8 to 12 weeks.
141..A nurse is developing a plan of care for a client who has a spinal fracture and
complete spinal cord transection at the level of C5. Which of the following
rehabilitation goals should the nurse add to the client’s plan of care?
Ability to self-feed with the use of adaptive equipment
Rational
A client who has a spinal cord transection at the level of the fifth cervical
vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow
movements. A realistic rehabilitation goal for the client is the ability to feed
himself with the use of adaptive equipment.
142..A nurse is creating a plan of care for a client who has a history of tonic-clonic
seizure disorder. Which of the following interventions should the nurse include?
(Select all that apply.)
Provide a suction setup at the bedside.
Elevate the side rails near the head when the client is in bed.
Place the bed in the lowest position.
Keep an oxygen setup at the bedside.
Incorrect. Furnish restraints at the bedside.
143..A nurse is caring for a client who has right-sided acoustic neuroma resulting
in impairment of cranial nerves IX and X. Which of the following actions should
the nurse take?
Place suction equipment at the client’s bedside.
Rational
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Cranialnerves IX(glossopharyngeal)andX(vagus)innervatethemuscles ofthe
soft palate, larynx, and pharynx. Impairment of these nerves places the client at
risk foraspiration, making it necessary for the nurse to have access to suction
for the client.
144..A nurse is caring for a client who has quadriplegia from a spinal cord injury
and reports having a severe headache. The nurse obtains a blood pressure reading
of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia.
Which of the following actions should the nurse take first?
Place the client in a high-Fowler’s position.
Rational
The client who is experiencing autonomic dysreflexia is at risk for a
cerebrovascular accident resulting from severe hypertension. According to the
safety and risk reduction priority setting framework, the nurse’s initial action
should be to place the client in a high-Fowler’s position to assist in providing
immediate reduction in blood pressure and intracranial pressure
145..A nurse is performing a mental status examination (MSE) on a client who has
a new diagnosis of dementia. Which of the following components should the
nurse include? (Select all that apply.)
Grooming
Long-term memory
Incorrect. Support systems
Affect
Incorrect. Presence of pain
146..A nurse in the emergency room is assessing a client who was brought in
following a seizure. The nurse suspects the client may have meningococcal
meningitis when assessment findings include nuchal rigidity and a petechial rash.
After implementing droplet precautions, which of the following actions should
the nurse initiate next?
Assess the cranial nerves.
Rational
The greatest risk to the client is from increased intracranial pressure (ICP)
which may lead to herniation of the brain and death. The nurse should perform
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
neurological assessments including evaluation of the cranial nerves at least every
4 hr. Early neurological changes to be monitoring for include a decrease in the
level of consciousness, the development of Cushing’s triad (severe hypertension,
widened pulse pressure, and bradycardia), and changes in pupillary reaction
147..A nurse is receiving a transfer report for a client who has a head injury. The
client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal
response, and 5 for best motor response. Which of the following is an appropriate
conclusion based on this data?
The client opens his eyes when spoken to.
Rational
A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is
oriented, and is able to localize pain.
The client can follow simple motor commands.
The client’s ability to follow commands would require a score of 6 for best motor
response.
The client is unable to make vocal sound.
The inability of the client to make vocal sounds would result in a score of 1 for
best verbal response.
The client is unconscious.
The unconscious client would have a score of 1 for eye opening and a 1 for best
verbal response.
148.. A nurse is caring for four hospitalized clients. Which of the following clients
should the nurse identify as being at risk for fluid volume deficit?
The client who has gastroenteritis and is febrile.
Rational
This client has two risk factors for the development of fluid volume deficit, or
dehydration. Gastroenteritis is characterized by diarrhea and may also be
associated with vomiting, so it can be a significant source of fluid loss. The client
who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic
rate, further putting the client at increased risk for dehydration. Consequently, this
is the client at greatest risk for fluid volume deficit.
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149..A nurse is performing discharge teaching for a client who has seizures and
a newprescriptionforphenytoin.Whichofthefollowingstatementsbythe
client indicates a need for further teaching?
I’ll be glad when I can stop taking this medicine.
Rational
Phenytoin is an anticonvulsant used to treat various types of seizures. Clients on
anticonvulsantmedicationscommonly require them forlifetimeadministration,
and phenytoin should not be stopped without the advice of the client’s provider.
150.. A nurse is caring for a client who has an intracranial pressure (ICP) reading of
40 mm Hg. Which assessment should the nurse recognize as a late sign of ICP?
(Select all that apply.)
Confusion
Incorrect. Tachycardia
Incorrect. Hypotension
Nonreactive dilated pupils
Slurred speech
151..A nurse is assessing a client who has Parkinson’s disease. Which of the
following manifestations should the nurse expect?
Bradykinesia
Rational
The nurse should expect to find bradykinesia or difficulty moving in a client
who has Parkinson’s disease.
152.. A nurse is teaching a female client who has a new prescription for
transdermal sumatriptan to treat migraine headaches. Which of the following
instructions should the nurse include?
Use contraception while taking this medication.
Rational
Sumatriptan can cause teratogenesis and should not be used during pregnancy.
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153.. A nurse is presenting discharge instructions to a client who has multiple
sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory
change. Which of the following nursing statements are appropriate?
Implement a schedule to include periods of rest.
Rational
The nurse should assist the client in developing a schedule that includes periods
of exercise followed by periods of rest to maintain muscle strength and
coordination.
154..A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of
the following manifestations should indicate to the nurse the client is experiencing
an increase in intracranial pressure (ICP)? (Select all that apply.)
Headache
Incorrect. Neck pain and stiffness
Slurred speech
Pupillary changes
Disorientation
Rational
Headache is correct. A client who has increasing ICP might manifest a headache.
Neck pain and stiffness is incorrect. Neck pain and stiffness are not
manifestations of increasing ICP.
Slurred speech is correct. A client who has increasing ICP might manifest slurred
speech.
Pupillary changes is correct. A client who has increasing ICP might manifest
pupillary changes.
Disorientation is correct. A client who has increasing ICP might display
disorientation or confusion.
155.. A nurse in an ICU is assessing a client who has a traumatic brain injury.
Which of the following findings should the nurse identify as a component of
Cushing’s triad?
Bradycardia
Increased ICP from TBI: Cushing’s triad: severe hypertension, bradycardia,
widened pulse pressure
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156.. A nurse in an ICU is planning care for a client who is in cariogenic shock. The
nurse should prepare to administer which of the following medications to
increase cardiac output?
Dopamine
Rational
Dopamine increases output by strengthening force of contractions)
157..A nurse in a provider’s office is assessing a client who has hypertension and
takes propranolol. Which of the following findings should indicate to the nurse
that the client is experiencing an adverse reaction to this medication?
Report of a night cough
158.. A nurse is assessing a client who has a comminuted fracture of the femur.
Which of the following findings should the nurse identify as an early manifestation
of a fat embolism.
Dyspnea
159.. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis.
Which of the following non pharmacological interventions should the nurse
suggest to the client to reduce pain?
Alternate application of heat and cold to the affected joints.
160.. A nurse is assessing a client who has diabetes insipidus. Which of the
following findings should the nurse expect?
Low urine specific gravity
161.. A nurse is assessing an older adult client who has heart failure and takes
digoxin. Which of the following findings should the nurse recognize as an
indication of digoxin toxicity?
Bradycardia
162.. A nurse is caring for a client 1 hr following a cardiac catheterization. The
nurse notes the formation of a hematoma at the insertion site and a decreased
pulse rate in the affected extremity. Which of the following interventions is the
nurse’s priority?
Apply firm pressure to the insertion site
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163.. 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.
164.. 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?
Hypoactive bowel sounds
165.. nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the
following should the nurse plan to administer?
Regular insulin (fast acting) 20 units IV bolus
Can be effective within 10 mins
Management: hydrate, correct acid-base imbalance (metabolic acidosis), &
decrease BGL)
166.. A nurse is caring for a client who has HIV. Which of the following findings
indicates a positive response to the prescribed HIB treatment?
Decreased viral load
167.. A nurse is caring for a client who is experiencing an acute myocardial
infarction. The nurse should identify which of the following findings as a
manifestation of cardiogenic shock?
Hypotension
168.. A nurse is caring for a client who is eight hours post-operative
following a total hip arthroplasty the client is unable to void on the bed
pan Which of the following actions should the nurse take first
Scan the bladder with a portable ultrasound
Rational
The first action should be using the nursing process which is assisting
the client scanning the bladder with a portable ultrasound device
will determine the amount of urine in the bladder
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169.. A nurse is teaching a client who has atrial fibrillation about the
purpose of wearing a Holter monitor. Which of the following
information should the nurse include in the teaching ?
This device can detect when you have an irregular heart rate
Rational
Because Holter reports and transmits electrical impulses of the heart
and alerts the nurse to dysrhythmias myocardial injury or conduction
defects a Holter monitor allows the client freedom of movement while
cardiac activity is recorded.
170.. A nurse is preparing a client for outpatient surgery. After the nurse inserts
the IV catheter, the client reports pain in the insertion area. Which of the
following actions should the nurse take?
Remove the catheter and insert another into a different site.
Rational
It is possible that the catheter is up against a valve or near a nerve and is causing
more pain than an IV catheter insertion should. The nurse should remove the
source of the pain and establish peripheral IV access elsewhere.
171..A nurse is reviewing the laboratory findings for a client who developed fat
embolism syndrome (FES) following a fracture. Which of the following
laboratory findings should the nurse expect?
Decreased serum calcium level
Rational
A decreased serum calcium level is an expected finding for FES, although the
reason for this finding is unknown.
172.. A nurse is assessing a client who is in skeletal traction. Which of the
following findings should the nurse identify as an indication of infection at the pin
sites?
Fever
Rational
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Manifestations of inflammation and infection at the pin sites include fever,
purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.
173.. A nurse is caring for a middle adult female client who reports that her
menstrual periods have become irregular and she has been having hot flashes.
The nurse should expect the client to have which of the following manifestations
associated with early menopause?
Dryness with intercourse
Menopause, the cessation of a woman’s menstrual periods, occurs when the
ovaries stop making estrogen. Because of the changes in the vagina, some women
can have dryness, discomfort, or pain during sexual intercourse.
174.. A nurse is caring for a client who is receiving a unit of packed red blood cells.
Fifteen minutes following the start of the transfusion, the nurse notes that the
client is febrile, with chills and red-tinged urine. Which of the following
transfusion reactions should the nurse suspect?
Hemolytic
175..A nurse is reviewing laboratory values for a client who has systemic lupus
erythematosus (SLE). Which of the following values should give the nurse the best
indication of the client’s renal function?
Serum creatinine
Rational
A renal function disorder reduces the excretion of creatinine, resulting in
increased levels of blood creatinine. Creatinine is a specific and sensitive indicator
of renal function.
176.. A nurse is providing teaching to a client who has a new diagnosis of type 2
diabetes mellitus. The nurse should recognize that the client understands the
teaching when he identifies which of the following as manifestations of
hypoglycemia? (Select all that apply.)
Blurred vision
Tachycardia Moist,
clammy skin
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177.. A nurse is reviewing the arterial blood gas values of a client who has
chronic kidney disease. Which of the following sets of values should the nurse
expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
Rational
The nurse should expect a client who has renal failure to have metabolic acidosis,
which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2.
Expected reference ranges for these laboratory values are as follows: pH 7.35 to
7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.
178.. A nurse is caring for a client who has congestive heart failure and is taking
digoxin daily. The client refused breakfast and is complaining of nausea and
weakness. Which of the following actions should the nurse take first?
Check the client’s vital signs.
Rational
It is possible that the client’s nausea is secondary to digoxin toxicity. By obtaining
vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin
toxicity. The nurse should withhold the medication and call the provider if the
client’s heart rate is less than 60 bpm.
179.. A nurse is teaching a female client who has a new diagnosis of
systemic lupuserythematosus(SLE).Thenurseshouldrecognizetheneed
forfurther teaching when the client identifies which of the following as a
factor that can exacerbate SLE?
Exercise
Rational
Deconditioning and muscle atrophy occurs as a result of lack of mobility. The
nurse should encourage client to engage in conditioning exercises alternated with
periods of rest.
180.. A nurse is caring for a client who has HIV. Which of the following laboratory
values is the nurse’s priority?
CD4-T-cell count 180 cells/mm3
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Rational
A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the
priority for the nurse to report to the provider.
181.. A nurse is working with a licensed practical nurse (LPN) to care for a client
who is receiving a continuous IV infusion. Which of the following findings reported
by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
The area surrounding the insertion site feels warm to the touch.
182.. A community health nurse is developing a pamphlet about breast self-
examination (BSE) for a local health fair. Which of the following instructions
should the nurse include?
Breasts can be examined in the shower with soapy hands.
The nurse should encourage clients to perform a BSE or do an extra examination
while showering. This allows clients to concentrate more easily on feeling for
tissue changes.
183.. A nurse is caring for four clients. Which of the following clients is at greatest
risk for a pulmonary embolism.
A client who is 12 hr postoperative following a total hip arthroplasty
184.. nurse is assessing a client with diabetes insipidus. The nurse knows that
which assessment finding is typical of this condition?
Polyuria
185.. A nurse is caring for a client after a craniotomy for pituitary tumor who
has developeddiabetes insipidus.Theclientisreceiving vasopressin (Pitressin).
The desired response to the medication is evident when the nurse observes
which of the following findings?
A decrease in urine output.
Rational
The major manifestations of diabetes insipidus are excessive urination and
extreme thirst. Pitressin is used to control frequent urination, increased thirst,
and
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loss of water associated with diabetes insipidus. A decreased urine output is the
desired response.
186.. A nurse in a providers office is reviewing lab results of a client who is being
evaluated for secondary hypothyroidism. Which of the following lab findings is
expected for a client who has this condition?
Decreased serum T3
187.. A nurse is reviewing the medical record of a client who is taking warfarin
for chronicatrialfibrillation. Which ofthefollowing valuesshould thenurse
identify as a desired outcome for this therapy
INR 2.5
188..A nurse is providing teaching for a female client who has recurrent urinary
tract infections. Which of the following information should the nurse include in
the teaching?
Void before and after intercourse
189.. A nurse is caring for a client who has increased intracranial pressure (ICP)
and is receiving mannitol via continuous IV infusion. The nurse should report
which of the following adverse effects of this medication to the provider?
Crackles heard on auscultation
190.. A nurse is providing teaching to a client who has breast cancer about the
adverse effects of chemotherapy. Which of the following client statements
indicates an understanding of the teaching?
I’ll call my doctor if I notice any unusual menstrual bleeding.
191.. A nurse is caring for a client who has chemotherapy- induced
peripheral neuropathy.Thenurseshouldexpecttheclienttoreporthaving
experienced which of the following symptoms?
Tingling feeling in the extremities
Peripheral neuropathy is a neurological disorder resulting from damage to the
peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses,
or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the
client is likely to experience pain, numbness, tingling, burning, or a loss of feeling
in the extremities.
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192.. A nurse is providing discharge teaching for a client who is postoperative following
a simple mastectomy. The client is to begin outpatient radiation therapy the next day.
Which of the following instructions about maintaining skin integrity should the nurse
include?
Do not apply heat to the area of irradiation.
Rational
This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner
and might lack tissue receptors that would otherwise alert the client to a potential burn
injury. When outdoors in sunlight, the client should wear protective clothing over the
area of irradiation.
193.. A nurse is caring for a client who is being evaluated for acromegaly. Which of
the following manifestations should the nurse expect to find during assessment?
(Select all that apply.)
Diaphoresis
Coarse facial features
Enlarged distal extremities is correct.
Muscle weakness is correct.
Diaphoresis
Acromegaly is a chronic metabolic disorder caused by an excess of growth
hormone after normal growth of the skeleton and other organs is complete. The
physical manifestations associated with acromegaly include enlarged sebaceous
glands with excessive sweating.
Coarse facial features is correct.
The physical manifestations associated with acromegaly include enlarged facial
bones with thickening of the skin, leading to coarse facial features.
Enlarged distal extremities is correct. The physical manifestations associated with
acromegaly include enlarged hands and feet with thickening of the skin.
Muscle weakness is correct. The physical manifestations associated with
acromegaly include fatigue and muscle weakness.
194.. A nurse in the post-anesthesia care unit is caring for a client who is postoperative
following a thoracotomy and lobectomy. Which of the following postoperative
assessments should the nurse give highest priority to?
Arterial blood gases
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Rational
According to the ABC priority-setting framework, the postoperative surgical client may
need supplemental oxygen in order to maintain normal blood oxygen levels. The
effectiveness of oxygenation is monitored using pulse oximetry and arterial blood
gases.
195.. A nurse is reviewing discharge instructions with a client following a right
cataract extraction. Which of the following instructions should the nurse include?
Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
The nurse should instruct the client to avoid activities that increase intraocular
pressure.
Therefore, the nurse should instruct the client to avoid lifting anything heavier than
4.5 kg (10 lb) for 1 week following surgery.
196.. A nurse is teaching a client about the seven warning signs of cancer. Which of the
following signs should the nurse include as manifestations of cancer? (Select all that
apply.)
A nonhealing sore
Incorrect. Bloating
Change in bowel pattern
Change in moles
Nagging cough
197.. A nurse is caring for a client who has expressive aphasia following a
cerebrovascular accident (CVA). Which of the following parameters should the nurse
use first in order to assess the client’s pain level?
a self-report pain rating scale
198.. A nurse is caring for a client who is hospitalized with active pulmonary
tuberculosis and is started on ethambutol therapy. The nurse should understand that
which of the following should be monitored?
Visual acuity
Rational
A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of
color discrimination, especially red and green. Baseline vision testing should be
performed before use, and visual acuity monitored at regular intervals.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
199.. A nurse in a clinic is teaching information about cervical polyps with a client
who has a new diagnosis. Which ofthe following information should the nurse include
in the teaching?
Postcoital bleeding may occur.
Rational
The client may experience postcoital bleeding, because the polyps are soft, fragile,
and bleed when touched.
200.. A nurse is providing teaching to a client who has breast cancer about the
adverse effects of chemotherapy. Which of the following client statements
indicates an understanding of the teaching?
I’ll call my doctor if I notice any unusual menstrual bleeding.
201.. A nurse is teaching a client who has vulvodynia about self-care measures to
alleviate symptoms. Which statement by the client indicates an understanding of the
teaching?
I should avoid the use of any lubricants
Rational
The nurse should recommend the use of natural oils such as olive oil for lubricant and
avoid lubricants containing propylene glycol.
“I should wear cotton undergarments.”
White cotton underwear is recommended for the client with vulvodynia.
202.. A staff nurse is teaching a client who has Addison’s disease about the disease
process. The client asks the nurse what causes Addison’s disease. Which of the
following responses should the nurse make?
It is caused by the lack of production of aldosterone by the adrenal gland.
Rational
Addison’s disease is caused by a lack of production of the adrenocorticotropic
hormones (cortisol and aldosterone) by the adrenal gland.
“It is caused by the overproduction of growth hormone by the pituitary gland.”
A client who has an overproduction of the growth hormone has acromegaly.
“It is caused by the overproduction of parathormone by the parathyroid
gland.”
A client who has hyperparathyroidism produces an excessive amount of parathormone.
202.. A nurse is planning care for a female client who has a T4 spinal cord injury and is
at risk for acquiring urinary tract infections. Which of the following actions should the
nurse include in the client’s plan of care?
Encourage fluid intake at and between meals.
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Rational
Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary
bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is
reduced, even for a client who has a spinal cord injury.
203.. A nurse in an emergency department is caring for a client who has a
sucking chest wound resulting from a gunshot. The client has a blood pressure of
100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min.
Which of the following actions should the nurse take?
Administer oxygen via nasal cannula.
Rational
The client has an increased respiratory rate and heart rate, indicating that she is
having respiratory difficulty. The sucking chest wound indicates the client has a
pneumothorax and/or a hemothorax. Administering oxygen will increase the
oxygen exchange in the lungs and the oxygen available to the tissues.
204.. A nurse is teaching a client who has septic shock about the development of
disseminated intravascular coagulation (DIC). Which of the following statements
should the nurse make?
DIC is caused by abnormal coagulation involving fibrinogen.
Rational
DIC is caused by abnormal coagulation involving the formation of multiple small
clots that consume clotting factors and fibrinogen faster than the body can produce
them, increasing the risk for hemorrhage.
205.. A nurse is providing dietary teaching to a client who has a history of
recurring calcium oxalate kidney stones. Which of the following instructions
should the nurse include in the teaching?
Drink 3 L of fluid every day.
Rational
The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to
dilute the urine and reduce the risk for stone formation.
206..A nurse is caring for a client who is experiencing menopausal symptoms and
asks the nurse about menopausal hormone therapy (HT). The nurse should inform
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
the client that HT is not recommended due to which of the following findings
in the client’s medical history?
History of breast cancer
Rational
Women with a history of breast cancer should be counseled against using HT.
207..A home health nurse is assessing an older adult client in the home who
has decreasedvisionduetoahistoryofglaucoma.Whichofthefollowing
findings should the nurse identify as a safety risk?
Scatter rugs are present in the kitchen.
Rational
Scatter rugs in the kitchen are a safety hazard. The client could trip on one of
the rugs and fall due to impaired vision.
208.. A nurse is preparing a client for a radiation treatment who is postoperative
following a mastectomy. The nurse should inform the client to expect which of the
following adverse effects from the treatment?
Fatigue
Rational
The nurse should inform the client to expect fatigue with her radiation treatment.
Fatigue occurs regardless of the radiation target site.
Alopecia
Alopecia is an acute adverse effect of radiation to the brain.
Diarrhea
Diarrhea is an acute adverse effect of radiation to the abdomen and pelvis.
209.. After radiation treatment, a client reports dryness, redness, and scaling of his
skin occurring within the designated radiation treatment markings. The nurse
should instruct the client to take which of the following actions?
Apply hydrating lotions.
Rational
The nurse should instruct the client to gently apply hydrating lotions that do not
contain metal, alcohol, or perfume.
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210.. A nurse is assessing a client who is in skeletal traction. Which of the
following findings should the nurse identify as an indication of infection at the pin
sites?
Fever
Rational
Manifestations of inflammation and infection at the pin sites include fever,
purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.
211..A nurse on a medical-surgical unit is caring for four clients who are 24 to 36
hr postoperative. Which of the following surgical procedures places the client at
risk for deep-vein thrombosis?
Hip arthroplasty
Rational
Clients who are postoperative following orthopedic procedures of the lower
extremities and clients who were placed in the lithotomy position for a procedure,
such as for gynecological or urological surgeries, are at a higher risk of
developing deep-vein thrombosis postoperatively.
212.. A nurse is caring for a client who is 2 hr postoperative following a
transurethral resection of the prostate (TURP) gland. Which of the following
assessments should the nurse view to be an indication of a postoperative
complication?
Output of burgundy colored urine
Rational
Output of burgundy colored urine may indicate venous bleeding, a potential
complication following a TURP. S
213.. A nurse is assessing a client before administering a unit of packed RBCs.
The nurseshould identifywhich of thefollowing data as most importantto obtain
prior to the infusion?
Temperature
Rational
The greatest risk to the client is injury from a blood transfusion reaction.
Therefore, the priority action is to take a baseline temperature measurement. The
nurse should then monitor the client’s temperature throughout the infusion as an
increase in temperature can indicate an adverse reaction.
ATI MEDSURG 2021 PROCTORED FINAL EXAMGRADED +
214.. A nurse in an ophthalmology clinic is interviewing a client who was referred
by his primary care provider for suspicion of cataracts. The nurse should expect the
client to report?
Having a decreased ability to perceive colors.
Rational
Symptoms of cataracts include painless blurred vision and a decrease in the ability
to perceive colors.
215.. A nurse is evaluating a client’s laboratory results. The nurse should recognize
that an increase in the client’s prostate specific antigen (PSA) laboratory value is
indicative of which of the following diagnoses?
Prostatic cancer
216.. A nurse is providing postoperative care for a client who has two chest tubes
in place following a lobectomy. The client asks the nurse the reason for having
two chest tubes. The nurse should inform the client that the lower chest tube is
placed for which of the following reasons?
draining blood and fluid from the pleural space
217.. A nurse is working with an assistive personnel (AP) who is assigned to bathe
a client who has herpes zoster. The AP asks the nurse if the herpes zoster is
contagious. Which of the following responses should the nurse make?
Herpes zoster is not contagious to people who have had chickenpox
218.. A nurse is caring for a client who is receiving total parenteral nutrition (TPN).
Which of the following actions should the nurse take?
check the clients capillary blood glucose level every 4 hr
ATI Proctored Exam Medical Surgical Form A
1. 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?
-Place hands on the upper abdomen during inhalation.
-Exhale slowly through pursed lips.
-Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)
-Position the mouthpiece 2.5 cm (1 in) from the mouth.
2. A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which of
the following findings should the nurse report to the surgeon?
-Heart rate 90/mm
-Hgb 8.2 g/dL
-Gastric ph of 3.0
-Absent bowel sounds
Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply
total obstruction. QSEN: Safety (Book page 1143)
3. A nurse is caring for a client who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
-Regular Insulin
-Furosemide
-Desmopressin
-Lithium Carbonate
Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or
by nasal spray.
Management focuses on controlling symptoms with drug therapy.
-The most preferred drug is desmopressin acetate (DDAVP), a synthetic form of
vasopressin given orally, as a sublingual “melt,” or intranasally in a metered spray. The
frequency of dosing varies with patient responses. Teach patients that each metered spray
delivers 10 mcg and those with mild DI may need only one or two doses in 24 hours.
-For more severe DI, one or two metered doses two or three times daily may be needed.
4. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times
daily for 3 years. Which of the following test should the nurse monitor?
Stool occult blood
-Urine for white blood cells
-Fasting blood glucose
-Serum calcium
5. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic
stroke. Which of the following is an appropriate nursing action?
-Start the therapy within 8 hrs. (within 6 hrs.)
-Insert an indwelling urinary catheter after therapy begins
-Monitor blood pressure every 30 minutes during infusion.
MARTINE ROSS 1
-Elevate the head of the bed between 25 and 30 degrees (to reduce ICP & promote venous
drainage, ATI page 89)
MARTINE ROSS 2
Assess for drug-related blood loss such as that caused by NSAIDs bychecking the stool for
gross oroccultblood.Older white women are the most likely to experience GI bleeding as
a result of taking these medications. (Book page 324)
6. 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. There are three tabs that contain separate categories of data.)
-Obtain a sputum sample for culture.
-Prepare the client for a chest x-ray.
-Initiate airborne precautions (question sounds like a respiratory issue)
-Administer ondansetron.
7. A nurse is admitting a client who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the client
is experiencing a myocardial infarction?
-QRS duration
-ST segment
-T-wave
PR interval
Examine the ST segment. The normal ST segment begins at the isoelectric line. ST elevation
or depression is significant if displacement is 1 mm (one small box) or more above or below
the line and is seen in two or more leads. ST elevation may indicate problems such as
myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with
hypokalemia, myocardial infarction, or ventricular hypertrophy. (Book page 670)
8. A nurse is teaching a client who has ovarian cancer about skin care following
radiation treatment. Which of the following instructions should the nurse include?
-Apply over the counter moisturizer to the radiation site
-Cover the radiation site loosely with a gauze wrap before dressing
-Use a soft washcloth to clean the area around the radiation site
-Pat the skin on the radiation site to dry it. (Book page 390)
Skin Protection During Radiation Therapy
• Wash the irradiated area gently each day with either water or a mild soap and water
as prescribed by your radiation therapy team.
9. A nurse is contacting the provider of a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse anticipate?
-Intravenous dexamethasone
-Transmucosal fentanyl
-Oral acetaminophen- not strong enough
-Intramuscular meperidine
Fentanyl is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has a fast onset
and short duration of action. It is recommended opioid for patients with end-organ failure
because it has no clinically relevant metabolites. It also produces fewer hemodynamic adverse
effects than other opioids; therefore, it is often preferred in patients who are hemodynamically
unstable such as the critically ill. (Book page 59)
• Use your hand rather than a washcloth when cleansing the therapy site to be gentler.
• Rinse soap thoroughly from your skin.
• If ink or dye markings are present to identify exactly where the beam of radiation is to be
focused, take care not to remove them.
•Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or
cloth.
• Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology
department on your skin at the radiation site.
• Wear soft clothing over the skin at the radiation site.
• Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the
radiation site.
• Avoid exposure of the irradiated area to the sun:
• Protect this area by wearing clothing over it.
• Try to go outdoors in the early morning or evening to avoid the more intense sun rays.
• When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when
the sun’s rays are most intense (10 AM to 7 PM).
• Avoid heat exposure.
10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that
the client has bounding peripheral pulses, hypertension, and distended jugular veins. The
nurse should anticipate administering which of the following prescribed medications?
Acetaminophen
-Furosemide (this patient has fluid overload from the transfusion)
Diphenhydramine
Pantoprazole
11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
-Lungs clear
-Hypoactive bowel sounds- Reduced motility, anorexia, nausea, constipation, and abdominal
distention are common. A paralytic ileus may occur when hypomagnesemia is severe.
-Blood pressure 90/50 mm Hg-hypomagnesemia causes hypertension, but this is too low,
abnormal
-Apical pulse 82/min
One aspect of the conduction problems is that, when serum magnesium levels are low,
intracellular potassium levels are also low. This changes the resting membrane potential in
cardiac muscle cells, slowing normal conduction and triggering ectopic beats.
12. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates
the position the nurse should assist the client into for this procedure?
– “Cannonball position on the side” picture #4 (ATI page 20)
13. A nurse is reviewing a clients ABG results: pH 7.42, PaCO2 30 mm Hg, and HCO3 -21
mEq/L. The nurse should recognize these findings as an indication of which of the
following conditions?
-Compensated respiratory alkalosis
-Uncompensated respiratory acidosis
-Metabolic acidosis
-Metabolic alkalosis
14. 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?
-Metoprolol
-Metformin
-Fluticasone
-Valproic Acid
15. A nurse is planning care for a client who is experiencing seizures secondary to meningitis.
Which of the following interventions should the nurse include in the plan of care? (Select all
that apply.)
-Assist the client to ambulate every 4 hr.
-Place a tongue blade at the bedside.
-Have suction equipment at the bedside.
-Dim the overhead lights.
-Apply a warming blanket.
16. A nurse is caring for a client who has a pressure ulcer with necrotic tissue and requires wet
to damp dressing changes daily. Which of the following types of debridement should the nurse
include in the plan of care?
-Enzymatic
-Surgical
-Autolytic
-Mechanical
17. A nurse is caring for a female who has toxic shock syndrome. Which of the following
findings should the nurse expect?
-Elevated platelet count
-Decreased total bilirubin
-Generalized rash
-Hypertension
18. A nurse is preparing to administer a medication for a client though a non-tunneled
percutaneous central catheter. Which of the following actions should the nurse take?
-Close the inline clamp
-Apply a local anesthetic to the skin
-Don sterile gloves
-Flush the catheter with 10 mL of 0.9% sodium chloride.
19. A nurse is caring for a client who was admitted with nausea, vomiting, and a possible
bowel obstruction. An NG tube is placed and set to a low intermittent suction. Which of the
following findings should the nurse report to the provider?
-The client reports being extremely thirst with a sore throat
-The drainage is bright green in color with brown fecal material
-The amount of drainage is gradually decreasing
-The client’s abdomen becomes distended and firm.
20. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the
following findings should the nurse expect?
-Elevated blood pressure
-Hypothermia
-Urine specific gravity 1.001
-Bun 15 mg/d:
21. The nurse is caring for a client who has hyperthyroidism and develops thyroid storm. Which
of the following instructions should the nurse give to the client regarding management of thyroid
storm?
-You will need to begin taking an ACE inhibition medication
-You will need a pacemaker to increase your heart rate
-You will need a cooling blanket to lower your body temperature
-You will need additional thyroid supplementation
22. The nurse is reviewing the medical record of a client who has acute gout. The nurse
should expect an increase in which of the following laboratory results?
-Uric acid
-Intrinsic factor
-Creatinine kinase
-Chloride level
23. A nurse is preparing to administer peritoneal dialysis to a client. Which of the following
actions should the nurse take?
-Use clean technique to access the catheter
-Chill the dialysate before administration
-Hang the drainage bag below the client’s abdomen
-Place the client in high-Fowler’s position.
24. A nurse in the emergency department is caring for a client who has deep partial thickness
burns over 30% of his body, including his upper chest and abdomen. Which of the following
actions is the nurse priority?
-Insert an 18-gauge IV catheter
-Administer tetanus toxoid
-Check the clients mouth for black particles
-Remove the clients burned clothing.Document continues below
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25. A nurse is presenting an in-service program about Parkinson’s disease (PD). Which of the
following statements should the nurse include in teaching?
-PD results form a decreased amount of dopamine in the client’s brain
-PD causes clients to have an increased sympathetic nervous system response
-PD results in the development of neurofibrillary tangles within the client’s brain
-PD manifestations worsen due to the clients decreased production of acetylcholine
26. A nurse is caring for a client who has a serum sodium level of 150 mEq/L. Which of
the following actions should the nurse take?
-Increase sodium in the client’s diet
-Administer hypotonic IV fluids to the client
-Restrict the client’s oral fluid intake
-Administer a beta blocker
27. A nurse is caring for a client who takes lisinopril for hypertension. Which of the following
client statements indicates an adverse effect of the medication?
-I seem to be bruising more easily
-I have a nagging, dry cough
-I have a heightened sense of taste
-I have to urinate frequently
28. A nurse is providing discharge teaching to a client following a modified left mastectomy with
breast expander. Which of the following statements by the client indicates an understanding of
the teaching?
-I will perform strength-building arm exercises using a 15-pound weight
-I should expect less than 25 mL of secretions per day in the drainage devices
-I will keep my left arm flexed at the elbow as much as possible
-I will have to wait 2 months before additional saline can be added to my breast expander
29. A nurse is caring for a client who has diabetes mellitus and has been following a treatment
plan for 3 months. Which of the following laboratory results should the nurse monitor to
determine long-term glycemic control?
-Oral glucose tolerance test results
-Fasting blood glucose level
-Glycosylated hemoglobin level
-Postprandial blood glucose level
30. A nurse is providing discharge teaching to a client who has chronic urinary tract infections.
The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following
instructions should the nurse include in the teaching?
-Take a laxative to prevent constipation
-Drink 2 to 3 L of fluids daily
-Take an antacid 30 min before taking the medication
-Monitor heart rate once daily
31. A nurse is providing teaching to a client who has a deep-vein thrombosis (DVT). Which of
the following findings should the nurse identify as a risk factor for the development of DVTs?
NSAID use
Cirrhosis
Hypertension
Oral contraceptive use
32. A nurse is caring for client who has Cushing’s disease. Which of the following actions
should the nurse take first? (Click on the Exhibit button below for additional information
about the client. There are three tabs that contain separate categories of data.)
-Auscultate the client’s lung sounds
-Check the client’s medication administration record for antihypertensive medications
-Determine the need for further glucose monitoring
-Verify the client’s understanding of sodium restriction
33. A nurse is assessing a client who has nephrotic syndrome. Which of the following findings
should the nurse expect?
-Proteinuria
-Hyperalbuminemia
-Flank pain
-Hypotension
34. A nurse is preparing to administer a 250 mL IV bolus of dextrose 5% in water to infuse
over 2 hr. for a client. The drop factor is 10 gtt./mL. The nurse should set the pump to
administer how many gtt./min? (Round the answer to the nearest whole number. Use a leading
zero if it applies. Do not use a trailing zero.)
gtt./min (change 2 hours to minutes = 120 minutes)
250 mL x 10 gtts/mL = 21 gtts/mL.
120 mins.
35. A nurse is assessing a client who has right-sided heart failure. Which of the following
assessment findings should the nurse expect to find?
-Poor skin turgor
-Pitting edema
-Oliguria
-S3/S4 galloping heart sounds
36. A nurse is caring for a client who has a newly inserted chest tube. The nurse should
clarify which of the following prescriptions with the provider?
-Administer morphine 2 mg IV bolus every 3 hr. PRN for pain
-Vigorously strip the chest tube twice daily
-Notify the provider when tidaling creases
-Assist the client out of bed 3 times daily
37. A nurse is teaching a client who is taking an ACE inhibitor for heart failure. Which of
the following instructions should the nurse include for home management of heart failure?
-Limit daily activity
-Obtain daily weight
-Monitor intake and output
-Use a salt substitute
38. A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which
of the following statements by the client indicates an understanding of the teaching?
-I need to check my pulse rate every day for a full minute
-When a microwave oven I in use, I need to stay out of the room
-I need to maintain pressure over the pacemaker site with an elastic bandage
-The pacemaker will deliver a shock if I develop a dysrhythmia
39. 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 followingimmunizations are
recommended for healthy adults after age 60? (Select all that apply.)
-Influenza
-Human Papillomavirus
-Meningococcal
-Herpes Zoster
-Pneumococcal polysaccharide
40. A nurse is assessing a client who is 4 hr. postoperative following arterial revascularization
of the left femoral artery. Which of the following findings should the nurse repot to the
provider immediately?
-Urine output 150 mL over 4 hr.
-Pallor in the affected extremity
-Bruising around the incisional site
-Temperature of 37.9 C (100.2 F)
41. A nurse is caring for an older adult who has not been eating. Which of the following
findings indicate dehydration?
-Capillary refill of 2 seconds
-Engorged neck veins
-Crackles auscultated bilaterally
-Diminished peripheral pulses (thready pulse)
42. A nurse is preparing to discharge a client who has a halo device and is reviewing
prescriptions from the provider. The nurse should clarify which of the following
prescriptions with the provider?
-May place a small pillow under the head when sleeping
-Take tub baths instead of showers
-Increase intake of fiber-rich foods.
-May operate a motor vehicle when no longer taking analgesics
43. A nurse is assessing for early signs of compartment syndrome for a client who has a short-
leg fiberglass cast. Which of the following findings should the nurse expect?
-Bounding distal pulses
-Intense pain with movement
-Capillary refill less than 2 seconds
-Erythema of the toes
44. A nurse is caring for a client who is postoperative following coronary artery bypass surgery
and reports shortness of breath. The nurse administers oxygen at 3 L/min and obtains arterial
blood gases 60 min later. Which of the following laboratory findings indicates a positive
response to the oxygen therapy?
-pH 7.32
-PaCO2 34 mm Hg
-Pa02 90 mm Hg
-Bicarbonate 20 mEq/L
45. A nurse is preforming a cranial nerve assessment on a client following a head injury. Which
of the following findings should the nurse expect if the client has impaired function of the
vestibulocochlear nerve (cranial nerve VIII)?
-Loss of peripheral vision
-Deviation of the tongue from midline
-Disequilibrium with movement
-Inability to smell
46. 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?
-Bilateral pupil diameter changes from 4 to 2 mm
-Glasgow Coma Scale score changes from 14 to 9
-Pulse pressure changes from 30 to 20 mm/hg
-WBC count changes from 9,000 to 16,000/mm3
47. A nurse is caring for a client who presents to the emergency department after experiencing a
heat stroke. Which of the following actions should the nurse take?
-Administer an antipyretic
-Apply a cooling blanket
-Assess axillary temperature every 15 min.
-Administer lactated Ringer’s
48. A nurse is caring for a client who is taking furosemide. The client has a potassium level of
3.1 mEq/L. Which of the following should the nurse assess first?
-Muscle weakness
-Urine output
-Level of orientation
-Cardiovascular status
49. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
-Administer a stool softener following the procedure
-Instruct the client to take deep breaths and hold them during the procedure
-Assist the client into the left lateral position during the procedure
-Ask the client to empty his bladder prior to the procedure
50. A nurse is caring for a client who is 6 hr. postoperative following a thyroidectomy. The client
reports tingling andnumbness in the hands. The nurse should identify this as a sign of which of
the following electrolyte imbalances?
-Hypernatremia
-Hypocalcemia
-Hypermagnesemia
-Hypokalemia
51. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBCs.
Which of the following findings is an indication of a hemolytic transfusion reaction?
-Hypotension
-Hypothermia
-Bradypnea
-Bradycardia
52. A nurse in an emergency department is caring for a client who has sinus bradycardia. Which
of the following actions should the nurse take first?
-Administer atropine to the client
-Initiate IV therapy for the client
-Measure the client’s blood pressure
-Prepare the client for temporary pacing
53. A nurse is caring for a client who has a prescription to discontinue a peripherally inserted
central catheter. Which of the following should the nurse take?
-Place a dry sterile dressing to the site after removal
-Measure the catheter after removal
-Apply slight pressure when resistance is met
-Remove the catheter with one continuous motion
54. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes
that the weights are resting on the floor. Which of the following actions should the nurse take?
-Remove one of the weights
-Increase the elevation of the effected extremity
-Pull the client up in bed
-Tie knots in the ropes near the pulleys to shorten them
55. A nurse is caring for a client who has a flail chest. Which of the following actions should the
nurse take?
-Implement fluid restriction
-Administer antibiotic medication
-Administer acetaminophen orally
-Provide humidified oxygen
56. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which
of the following manifestations should the nurse include in the teaching?
-Hypocarbia
-Hypoxemia
-Hyperventilation
-Hypovolemia
57. A nurse is caring for a client who is experiencing a seizure. Which of the following actions
should the nurse take first?
-Clear items from the client’s surrounding area.
-Obtain the client’s vital signs
-Loosen the client’s restrictive clothing
-Lower the client to the floor
58. A nurse is teaching a client who is receiving total parenteral nutrition at home through a
central venous access device about transparent dressing changes. Which of the following
instructions should the nurse include in the teaching?
-Use clean technique when changing the dressing
-Wear a mask during the dressing change
-Replace the extension tubing with each dressing change
-Change the dressing every 48hr.
59. A nurse is caring for a client in the emergency department who experienced a full-
thickness burn injury to the lower torso 1 hour ago. Which of the following findings should
the nurse expect?
-Decreased respiratory rate
-Urinary diuresis
-Hypotension
-Bradycardia
60. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
-Yellow sclera
-Mental confusion
-Palmar erythema
-Spider angiomas
61. 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 apply a lubricating lotion to the cracked areas on the soles of my feet every morning
-I use my heating pad on a low setting to keep my feet warm
-I soak my feet in hot water before trimming my toenails
-I rest in my recliner with my feet elevated for about an hour every afternoon
62. A nurse is teaching a client who has a new prescription for (alendronate to treat)
osteoporosis. Which of the following instructions should the nurse include in the
teaching?
-Swallow the medication with 120 mL (4oz) of water
-Sit upright for 30 min. after taking the medication
-Take the medication with lunch
-Take the medication with a vitamin E supplement
63. A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the follow
statement should the nurse include in the teaching?
-Exhale fully before bringing the inhaler to your lips
-Do not shake your inhaler before use
-Use peroxide to clean the mouthpiece of your inhaler
-Depress the canister after you exhale
64. 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?
-Imitate beta blocker therapy
-Administer IV fluids to the client
-Insert a urinary catheter
-Prepare the client for an intravenous pyelogram
65. 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?
-Massage the reddened areas three times daily
-Turn and reposition the client every 4 hr.
-Support bony prominences with pillows
-Apply an occlusive dressing
66. A nurse is reviewing the medical record of a client who is to undergo open heart surgery.
Which of the following findings should the nurse report to the provider as a contraindication to
receive heparin?
-Thrombocytopenia
-COPD
-Thalassemia
-Rheumatoid arthritis
67. A nurse is caring for a client who as completed 10 daily cycles of total parenteral nutrition
(TPN). Which of the following findings indicates that the client is receiving adequate TPN
supplementation?
-Weight gain of 9.1 kg (20 lb.)
-BUN level of 15 mg/dL
-Improved mobility
-Potassium level of 2.5 mEq/L
68. A nurse is providing teaching to a client who is postoperative following a partial
glossectomy. Which of the following statements by the client indicates an understanding of the
teaching?
-I will inspect my mouth once each week for sores
-I will drink orange juice to increase my vitamin C intake
-I will consume canned soap whenever sores appear in my mouth
-I will rinse my toothbrush with hydrogen peroxide and water after each use
69. A nurse is preforming an ear irrigation for a client. Which of the following actions should the
nurse take?
-Use cool fluid for irrigation
-Insert the tip of the syringe 2.5 cm (1 in) into the ear canal
-Tilt the client’s head 45 degrees
-Point the tip of the syringe toward the top of the ear canal
70. 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?
-Administer PRN pain medication
-Check the client’s urine output
-Reposition the client in bed
Increase the client’s fluid intake
71. A nurse is providing teaching for a client who has diabetes mellitus about the self-
administration of insulin. The client has prescriptions for regular and NPH insulins. Which
of the following statements by the client indicates an understanding of the teaching?
-I will store prefilled syringes in the refrigerator with the needle pointed downward
-I will shake the NPH vial vigorously before drawing up the insulin
-I will draw up the regular insulin into the syringe first (clear before cloudy)
-I will insert the needle at a 15-degree angle
72. A nurse is caring for a client who has systemic lupus erythematous. During assessment,
which of the following should the nurse expect to find?
-Esophagitis
-Tophi
-Bull eye lesions
-Joint inflammation
73. A nurse is monitoring an older adult client who has an exacerbation of chronic
lymphocytic leukemia. The nurse notes petechiae on the client’s skin.
-Institute bleeding precautions
-Determine the client’s blood type
-Avoid administering IV pain medication
-Implement airborne precautions
74. A nurse is caring for a client who is receiving TPN nutrition (TPN). Which of the following
actions are appropriate? (Select all that apply.)
Increase the rate of infusion if administration is delayed
Monitor serum blood glucose during infusion
Infuse 0.9% sodium chloride if the solution is not available
Verify the solution with another RN prior to infusion
Obtain the client’s daily weight
75. A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the
priority intervention by the nurse?
-Begin bicarbonate continuous IV infusion
-Administer 0.9% sodium chloride
-Check potassium levels
-Initiate a continuous IV insulin infusion
76. A nurse is reviewing the laboratory results of a female client who ask about acupuncture as
treatment for chemotherapy-induced nausea and vomiting. Which of the following
laboratory results should the nurse identify as a contraindication to receiving acupuncture?
Hemoglobin 12 g/dL
C-reactive protein 0.7 mg/dL
Platelets 160,000/mm3
Absolute neutrophil count 500/mm3
77. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain
level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse
take?
-Gently massage the area around the client’s incision
-Apply an ice pack to the client’s knee
-Perform range of motion exercises to the client’s knee
-Place pillows under the client’s knee
78. 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
-Hypertension
-Positive chvostek sign
-Oliguria
79. A nurse at a long-term facility is assessing an older adult client. Which of the following
findings should the nurse identify as an indication that the client has a recall memory
impairment?
-Inability to state his current age
-Inability to name the members of his family
-Inability to count backwards from 10
-Inability to state what he had for dinner last night
80. A nurse on an intensive care unit is planning care for a client who has increased intra
cranial pressure following a head injury. Which of the following IV medications should
the nurse plan to administer?
-Chlorpromazine
-Mannitol
-Dobutamine
-Propranolol
81. A nurse on a medical unit is planning care for a group of clients. Which of the following
clients should the nurse see first?
-A client who has left-sided paralysis and slurred speech from a prior stroke
-A client who has multiple sclerosis and reports ataxia and vertigo
-A client who has thrombocytopenia and reports a nosebleed
-A client who has chronic obstruction pulmonary disease and an oxygen saturation of 89%
82. A home care nurse is planning to use nonpharmacological pain relief measures for an older
adult who has sever chronic back pain. Which of the following guidelines should the nurse use?
Discontinue opioids before trying nonpharmacological methods of pain relief
Pain relief from the use of heat and cold continues for several hours after removal of the stimulus
Use imagery with clients who have difficulty with focus and concentration
Distraction changes the client’s perception of pain, but does not affect the cause
83. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure.
Which of the following statements indicates that the client understands a potential adverse
effect of this medication?
-I’m going to include more cantaloupe in my diet
-I will try to limit foods that contain salt
-I will check my pulse before I take the medication
-I’ll check my blood pressure, so it doesn’t get too high
84. A nurse is providing discharge teaching for a client who has HIV. Which of the following
information is the priority for the nurse to review with the client?
-Describe your daily medication schedule
-Name a few things you will change about your diet
-List some ways you can cope with the stress of your illness
-Tell me why it’s important to have your CD4+ count checked
85. A nurse is caring for a client who has an endotracheal tube. Which of the following actions
should the nurse take to verify the tube placement?
-Deflate the cuff to check for tube placement
-Place the clients head and neck in a flexed position
-Document the tube length where it passes the chin
-Observe for symmetry of chest expansion
86. A nurse in an emergency department is caring for a client who is receiving treatment for
excessive ingestion of antacids. The nurse should identify that this client is at risk for which
of the following acid-base imbalances?
-Metabolic acidosis
-Respiratory acidosis
-Respiratory alkalosis
-Metabolic alkalosis
87. A nurse is assessing a client for a positive Chvostek’s sign following a thyroidectomy. Which
of the following areas on the client’s head should the nurse tap to assess the client for tetany?
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds
to your answer.) (The cheek area)
88. A nurse is caring for a client who has advance liver disease. Which of the following
laboratory results should the nurse monitor when assessing this client?
-Phosphate level
-Serum troponin
-Serum ammonia
-Glucose level
89. A nurse is caring for a client who has a pneumothorax and a chest tube with the closed
water-seal drainage system. Which of the following actions should the nurse take?
-Strip or clear the chest tube every 8 hours
-Change the chest tube site dressing every 24 hr.
-Empty the system at least every 8 hours
-Refill the water chamber if the fluid level is low
90. a nurse in an emergency department is reviewing a client’s ECG reading. Which of the
following finding should the nurse identify as an indication that the client has first-degree heart
block?
-Prolonged PR intervals
-More P waves than QRS complexes
-Non discernible P waves
-No correlation between P and QRS waves
91. A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify
a sequence of steps the nurse should follow. (Move the steps into the box on the right, placing
them in order of performance. Use all the steps.)
Correct Order
Verify blood compatibility with another nurse Obtain venous assess using a 19-gauge
needle
Remain with the client for the first 15 to 30
minutes of the infusion
Obtain the unit of packed RBCs from the
blood bank
Obtain the unit of packed RBCs from the
blood bank
Verify blood compatibility with another
nurse
Initiate transfusion of the unit of packed
RBCs
Initiate transfusion of the unit of packed
RBCs
Obtain venous assess using a 19-gauge needle Remain with the client for the first 15 to 30
minutes of the infusion
92. A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted
central catheter (PICC). Which of the following statement should the nurse include in the
teaching?
-We can draw blood samples from the PICC for diagnostics test
-We will replace the PICC every month
-We will change the dressing daily
-We can measure your blood pressure in either arm
93. A nurse is assessing a client who has pyelonephritis and reports flank pain. Which of the
following actions should the nurse take?
-Auscultate for a bruit over the costovertebral area.
-Assist the client to a sitting position
-Thump the area of tenderness directly with a closed fist
-Percuss the side of tenderness first
94. A nurse is assessing a client who has acute kidney injury failure. Which of the following
findings should the nurse report to the provider?
-Peripheral pulses 2+ bilaterally
-Creatinine 0.8 mL/dL
-Urine specific gravity 1.045
-Weight gain 1.1 kg (2.4 lb.) in 24 hr.
95. A nurse is caring for an older adult client who is 72 hr. postoperative following a total hip
arthroplasty. The client requires a PRN medication prior to ambulation. Which of the
following medications should the nurse anticipate administering?
-Naproxen
-Meperidine
-Indomethacin
-Oxycodone
96. A nurse is providing discharge 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?
-Change your pet’s litter box daily
-Wash your perineal area two times each day with antimicrobial soap
-Change the water in your drinking glass every 4 hours
-Wash your toothbrush in the dishwasher once a month
97. A nurse is caring for a client who has Haemophiles influenza type B. Which of the following
types of isolation should the nurse implement?
-Droplet
-Airborne
-Protective
-Contact
98. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of
the following finding should the nurse include as an indication the client is no longer infectious?
-Negative sputum cultures for acid-fast bacillus
-Positive QuantiFERON-TB Gold test
-Mantoux skin test revealing an induration of less than 1 mm
-Client no longer coughing up blood-tinged sputum
99. A nurse is working in the emergency department is caring for a client who has a burn injury.
After securing the client’s airway, which of the following interventions should the nurse take
first?
-Cleanse the client’s wounds
-Administer analgesic medication
-Start an IV with a large-bore needle
-Increase the room temperature
100. 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?
-Obtain ABG values
-Perform an ECG
-Turn the client to his left side
-Clamp the catheter