ATI MED SURG ALL VERSIONS
WITH 100% CORRECT VERIFIED
QUESTIONS AND ANSWERS
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ATI MED SURG PROCTORED EXAM
VERSION 1
A nurse is reviewing the medical record for an older adult client who is
experiencing nausea and vomiting. Based on the client data, which of the following
actions should the nurse take?
Exhibit 1
Exhibit 2
Exhibit 3
Diagnosis Results
Sodium 142 mEq/ Potassium 4.2 mEq/L BUN 36 mg/dL Creatinine 1.4 mg/dL
Nurses' Notes
1200: Alert and oriented x3 Lungs clear to auscultation Decreased skin turgorDry
mucous membranes
Graphic Record
Temperature0800: 37.7° C (99.9° F) 1200: 37.2° C (99.0° F) Pulse0800: 96/min
1200:105/min Respiratory rate0800: 18/min1200: 20/minBlood pressure0800;
118/62 mmHg 1200: 104/65 mm Hg
a) Encourage the client to ambulate.
b) Administer an antipyretic medication.
c) Notify the charge nurse of the client's BUN level
d) Keep the temperature in the client's room warm.
EXPLANATION
The client's BUN level is above the
expected reference range of 10 to 20 mg/dL, which indicates dehydration and
impaired renal function. The nurse should notify the charge nurse of this finding
and anticipate interventions to restore the client's fluid volume.
A nurse is providing information regarding transmission-based precautions for a
client who has Clostridium difficileto an assistive personnel (AP). Which of the
following instructions should the nurse include? (Select all that apply).
a) "Provide the client with disposable utensils and dishes for meals."
b) "Leave blood pressure equipment in the client's room."
c) "Clean contaminated surfaces with a bleach solution."
d) "Use an alcohol-based hand sanitizer after client care."
e) "Wear a face mask when in the client's room."
EXPLANATION
Clients who have C. difficile require contact precautions, which include using
disposable utensils and dishes during meals to prevent exposure to contaminants
by others.
(When using contact precautions, the health care staff should dedicate equipment
to single-client use to prevent transmission of the pathogen.)
The health care staff should use a bleach solution to clean equipment to prevent
transmission of the pathogen.
A nurse is admitting a client who is suspected having active tuberculosis (TB).
Which of the following actions should the nurse take first? (chap. 20)
a) Administer antituberculosis medication.
b) Institute airborne precautions.
c) Obtain sputum cultures.
d) Auscultate breath sounds
EXPLANATION
The greatest risk from this client is transmitting TB to
staff and other clients. Therefore, the first action the nurse should take is to
implement
airborne precautions.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain.
Which of the following actions should the nurse take?
a) Fill the bulb reservoir with 0.9% sodium chloride.
b) Allow the Jackson-Pratt drain to hang freely.
c) Cut a slit in a gauze sponge and apply it around the tubing insertion site.
d) Compress the bulb reservoir and then close the drainage valve.
EXPLANATION
(The nurse should fully
compress the bulb reservoir and then replace the valve plug using aseptic
technique to
establish suction after emptying or activating a Jackson-Pratt drain.)
A nurse is reinforcing teaching with the parent of a toddler who has type I
diabetes mellitus and whose prescription has been changed from regular insulin
to lispro insulin. Which of the following information should the nurse include in the
teaching?
a) Lispro is given once a day.
b) Lispro should be given before eating
c) Lispro cannot be given with other insulin.
d) Lispro does not cause hypoglycemia.
EXPLANATION
(Lispro insulin should be given around mealtime,
A nurse is reinforcing teaching with a client who has microcytic anemia and is
prescribed a daily iron supplement. The nurse tells the client to consume foods
containing vitamin C when taking the supplement to enhance iron absorption.
Which of the following client food choices indicates an understanding of the
teaching?
a) 1 cup cooked brown rice
b) 1 cup boiled broccoli
c) 1 cup cottage cheese
d) 1 cup cooked kidney beans
EXPLANATION
(The nurse should determine that choosing boiled broccoli indicates
an understanding of the teaching because 1 cup contains 101 mg of vitamin C per
serving.)
A nurse is assisting with the development of a plan of care to manage pain for a
client who has herpes zoster with lesions on the lower extremities. Which of the
following interventions should the nurse include in the plan of care?
a) Keep bed linens off of the affected areas.
b) Position a heat lamp over the lower extremities.
c) Apply warm, moist compresses to the affected areas.
d) Initiate droplet isolation precautions.
EXPLANATION
(The nurse should keep bed linens off of the affected areas using a bed cradle,
which will relieve pain caused by the linens rubbing against the lesions.)
A nurse is reinforcing teaching with an older adult client who has osteoporosis.
Which of the following instructions should the nurse in the teaching?
a) "Place throw rugs on wooden floors at home."
b) "Supplement your diet with vitamin E."
c) "Swim laps for 20 minutes twice per week."
d) "Take calcium supplements with meals."
EXPLANATION
The nurse should instruct the client to take
calcium carbonate supplements with or following meals to increase absorption
and
effectiveness.
A nurse is reviewing the medication record of a client who is taking digoxin. Which
of the following medications should the nurse identify as increasing the risk for
the client to develop digoxin toxicity?
a) Potassium chloride
b) Famotidine
c) Levothyroxine
d) Furosemide
EXPLANATION
The nurse should identify that loop diuretics, such as furosemide, increase
the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia
increases the risk for the development of digoxin toxicity.
A nurse is reinforcing teaching about insulin injections with an adult client who
weighs 45.4 kg (100 lb.). Which of the following statements by the client indicates
an understanding of the teaching?
a) "I should insert the needle at a 90-degree angle."
b) "I should give my shot in my belly tissue."
c) "I will pull back on the syringe plunger to look for blood before I push the
medication
in."
d) "I will use the side of my hand to pull my skin to the side prior to administering
the
insulin." -
EXPLANATION
Clients who have low body weights can
have very little subcutaneous tissue. Therefore, the nurse should instruct the
client to
administer the medication in the upper abdomen for proper absorption. [Show Less]