ATI Med - Surg part A (2019) – Chamberlain College
of Nursing
MED-SURG PART A
1. A nurse is reinforcing discharge teaching about wound care
with a fa
... [Show More] mily member of a client who is postoperative.
Which of the following should the nurse include in the
teaching?
a) Administer an analgesic following wound care. (The nurse
should remind the family member to administer an analgesic
prior to wound care to prevent discomfort.)
b) Irrigate the wound with povidone iodine. (The nurse should
remind the family member to irrigate the wound with 0.9%
sodium chloride.)
c) Cleanse the wound with a cotton-tipped applicator. (The nurse
should remind the family member to avoid using a cottontipped applicator to cleanse the wound because the fibers can
become embedded in the wound, cause infection, and delay
wound healing.)
d) Report purulent drainage to the provider. (The nurse should
remind the family member to report signs of infection,
including purulent drainage.)2. A nurse is caring for a client who has bacterial meningitis.
Upon monitoring the client, which of the following findings
should the nurse expect?
a) Flaccid neck (The nurse should recognize that nuchal rigidity,
rather than a flaccid neck, is a manifestation of meningitis.)
b) Stooped posture with shuffling gait (The nurse should recognize
that a stooped posture with shuffling gait is a manifestation of
Parkinson's disease, not a manifestation of meningitis.)
c) Red macular rash (The nurse should expect to find a red
macular rash, sometimes called a petechial rash, which is a
manifestation of meningococcal meningitis.)
d) Masklike facial expression (The nurse should recognize that a
masklike expression is a manifestation of Parkinson's disease,
not a manifestation of meningitis.)
3. A nurse is contributing to the plan of care for an older adult
client who is at risk for osteoporosis. Which of the following
interventions should the nurse include to prevent bone
loss?
a) Increase fluid intake. (Fluid intake is beneficial for general
health and wellness, and it helps to treat some disorders.
Caffeine and alcohol intake can increase the client's risk of
developing osteoporosis. However, fluid intake does not prevent
bone loss.)
b) Encourage range-of-motion exercises. (Range-of-motion
exercises are beneficial for general health and wellness, and
they help to maintain flexibility and prevent contractures.
However, range-of-motion exercises do not prevent bone loss.)c) Massage bony prominences. (Massaging bony prominences
should be avoided because it can traumatize deep tissues.)
d) Encourage weight-bearing exercises. (Weight-bearing exercises,
such as walking, can maintain bone mass by reducing bone
demineralization, thus helping to prevent osteoporosis.)
4. A nurse is collecting data from a client and notices several
skin lesion. Which of the following findings should the
nurse report as possible melanoma?
a) Scaly patches (The nurse should report scaly patches as possible
basal or squamous cell carcinoma.
b) Silvery white plaques (The nurse should report silvery white
plaques as possible psoriasis.)
c) Irregular borders (The nurse should report irregular borders of
a skin lesion to the provider because it can indicate malignant
melanoma.)
d) Raised edges (The nurse should report raised edges of a skin
lesion as possible basal cell carcinoma.)
5. A nurse is reinforcing discharge teaching to prevent
dumping syndrome for a client following a partial
gastrectomy for ulcers. Which of the following information
should the nurse include in the teaching?
a) Avoid liquids at mealtimes. (The nurse should remind the client
to avoid drinking liquids at mealtimes to prevent the food from
emptying into the small bowel too quickly.)
b) Exclude eating starchy vegetables. (The nurse should remind
the client to include starchy vegetables in the meal plan to slow
gastric emptying.)c) Avoid eating high-protein meals. (The nurse should remind the
client to eat high-protein meals to help slow gastric emptying.)
d) Plan to increase intake of sweetened fruits. (The nurse should
remind the client to exclude sweetened fruits from the diet to
help slow gastric emptying.)
6. A nurse is collecting data on a client who is scheduled for a
cardiac catheterization. Which of the following laboratory
levels should the nurse review prior to the procedure?
a) Albumin (Albumin levels determine the amount of protein the
liver produces in the body and is an indication of hepatic
function and nutritional status. However, it is not impacted by
contrast media used for cardiac catheterization. Therefore, the
nurse does not need to review this laboratory level prior to a
cardiac catheterization.)
b) Phosphorus (Phosphorus is an electrolyte that combines with
calcium to maintain bone health and is involved as an energy
source in metabolism. However, it is not impacted by contrast
media used for cardiac catheterization. Therefore, the nurse
does not need to review this laboratory level prior to a cardiac
catheterization.)
c) TSH (TSH levels determine thyroid function. However, it is not
impacted by contrast media used for cardiac catheterization.
Therefore, the nurse does not need to review this laboratory
level prior to a cardiac catheterization.)
d) BUN (BUN levels indicate kidney function. Contrast media used
during cardiac catheterization can cause renal failure. The nurseshould review this laboratory level to determine if the client can
tolerate the IV contrast dye during the procedure.)
7. A nurse is reinforcing glycosylated hemoglobin (HbA1c)
testing with a client who has diabetes mellitus. Which of the
following statements indicates that the client understands
the teaching?
a) "The HbA1c test should be performed 2 hr after I eat a meal that
is high in carbohydrates." (The nurse should remind the client
that carbohydrate consumption is not required for HbA1c
testing.)
b) "The HbA1c test can help detect the presence of ketones in my
body." (The nurse should remind the client that urine testing
can detect ketone bodies.)
c) "I will have my HbA1c checked twice per year." (An HbA1c test
provides the client's average glucose level for the preceding 3
months. The nurse should instruct the client to have her HbA1c
tested twice yearly to manage her glucose.)
d) "I will plan to fast before I have my HbA1c tested." (The nurse
should remind the client that fasting is not required for HbA1C
testing.)
8. A nurse is examining a client’s IV site and notes a red line
up his arm. The client reports a throbbing, burning pain at
the IV site. The nurse should identify that the client’s
manifestations indicate which of the following
complications of IV therapy?
a) Thrombophlebitis (The nurse should identify pain, warmth, and
a red streak up the arm as indications of thrombophlebitis.)b) Infiltration (The nurse should identify swelling and cool skin at
the IV site as indications of infiltration.)
c) Hematoma (The nurse should identify swelling and bruising as
indications of a hematoma that can develop by not holding
enough pressure after discontinuing the IV.)
d) Venous spasms (The nurse should identify cramping at or above
the insertion site and numbness as indications of venous
spasms.)
9. A nurse is reinforcing teaching about management of
constipation with a client who has hypothyroidism. Which
of the following should the nurse include in the teaching?
a) Increase intake of fiber-rich foods. (The nurse should instruct
the client to increase the amount of fiber-rich foods in his diet.
Dried beans and brown rice are examples of fiber-rich foods.)
b) Take a laxative every morning. (The nurse should instruct the
client to initially take a laxative in the evening to stimulate the
evacuation of stool. However, the nurse should instruct the
client to use laxatives sparingly.)
c) Maintain a fluid intake of 1200 mL per day. (The nurse should
instruct the client to increase his fluid intake to 2,000 mL per
day to maintain soft stools.)
d) Limit activity to preserve energy. (The nurse should instruct the
client to increase activity to stimulate the evacuation of stool.)
10. A nurse is caring for a client who is at risk for
developing pressure ulcers. Which of the following actions
should the nurse take?a) Position pillows between the bony prominences. (The nurse
should use positioning devices to keep bony prominences from
being in direct contact with each other, which will prevent skin
breakdown and pressure ulcer development.)
b) Check for incontinence every 3 hr. (The nurse should check the
client for incontinence at least every 2 hr to prevent skin
breakdown.)
c) Massage reddened areas of the skin. (The nurse should avoid
massaging reddened areas of the skin, which can lead to the
formation of a pressure ulcer by damaging underlying tissue.)
d) Elevate the head of the bed to 45°. (The nurse should avoid
elevating the head of the bed to an angle greater than 30°. An
angle greater than 30° can cause shearing of the skin, which
leads to tissue injury and pressure ulcer development.)
11. A nurse is contributing to the plan of care for a client
who has peripheral arterial disease (PAD) of the lower
extremities. Which of the following interventions should
the nurse include?
a) Place moist heat pads on the extremities. (The nurse should
avoid applying heat to the client's extremities to prevent injury
due to decreased sensation.)
b) Perform manual massage of the affected extremities. (The nurse
should avoid massaging the client's lower extremities if the
client is having pain from ischemia. A warm environment and
keeping the client warm will help with circulation to the
extremities and decrease pain through vasodilation.)c) Dangle the extremities off the side of the bed. (The nurse should
include in the plan of care to have the client dangle the lower
extremities off the side of the bed to aid in reducing pain by
increasing arterial blood flow. The client should not raise the
lower extremities above the level of the heart when resting in
bed because it impairs arterial blood flow.)
d) Apply support stockings before getting out of bed. (The nurse
should avoid applying support stockings to the lower
extremities because support stockings interfere with the arterial
blood flow to the lower extremities.)
12. A nurse is caring for a client who has meningococcal
pneumonia. Which of the following personal protective
equipment should the nurse use?
a) Gown (The nurse should wear a gown when caring for a client
who requires contact precautions.) [Show Less]
