ATI Med-Surg Proctored Exam
1) A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which of the
following findings
... [Show More] should the nurse expect?
- Nonresponsive Commands
2) A nurse is collecting data from a client who has coronary artery disease. Which of the following
manifestations should the nurse identify as an indication that the client has angina
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest
3) A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the
nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic
4) A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the
following instructions should the nurse include?
- Examine your testicles after a warm shower
5) A nurse is collecting data from a client who has tuberculosis and started combination therapy 2months ago.
Which of the following diagnostic results indicates that the client is adhering to the medication regimen.
- A negative sputum culture
6) A nurse is collecting data from a client who has bacterial meningitis. Which of the following findings should
the nurse expect?
- Severe Headache
7) A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the
client indicated an understanding of the teaching
- I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize
8) A nurse is reinforcing teaching with a male client who has right sided hemiparesis about preforming ADL’s.
Which of the following instructions should the nurse include in the teaching
- Comb your hair with the unaffected arm
9) A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of dyspnea.
Which of the following instructions should the nurse include?
- Used the pursed lip breathing technique
10) A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity. Which of
the following instructions should the nurse include in the teaching
- Apply elastic support hoes before getting out of bed in the morning
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse
expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate oxygen exchange
in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the diaphragm becomes
permanently flattened by overdistention of the lungs. The muscles of the rib cage also become rigid, and the ribs
flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity, which decreases
oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity; consequently, respirations
become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less oxygen being
delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should
the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of cortisol or by
excessive use of corticosteroids. Buffalo hump, a collection of fat between the shoulders, is a common
manifestation of Cushing's syndrome.Purple striations is correct. Purple striations on the skin of the abdomen,
thighs, and breasts are a common manifestation of Cushing's syndrome. This is due to the collection of body fat in
these areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who have
this manifestation present with a round, red, full face.Tremors is incorrect. Tremors are not a common finding of
Cushing's syndrome.Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a
protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following
actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to replace the
cerebrospinal fluid that was removed during the procedure and reduce the risk for a headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a hematoma at the
insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the
risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for this client.
A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established.
Which of the following instructions should the nurse include in the teaching?
1) Empty the pouch immediately after meals.
2) Change the entire appliance once a day.
3) Limit fluid intake.
4) Avoid medications in capsule or enteric form.
A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an
escharotomy and wants to know what the procedure involves. Which of the following statements is
appropriate for the nurse to make?
1) "An escharotomy surgically removes dead tissue."
2) "A cannula will be inserted into the bone to infuse fluids and antibiotics."
3) "A piece of skin will be removed and grafted over the burned area."
4) "Large incisions will be made in the burned tissue to improve circulation."
A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to r [Show Less]