ATI MEDSURG 2021 PROCTORED EXAM – LATEST GUIDE
1. Following long-term administration of warfarin sodium to a client with a medical diagnosis of deep
... [Show More] vein thrombosis, the nurse should expect which treatment?
a. The hemoglobin will be greater than 10 g/dl
b. The hematocrit will be less than 35%
c. The PT will be 1.5 times the normal-good
d. The PTT will be 1.5 times the normal-
2. A client who has been taking finasteride, an enzyme (5 alpha reductase) inhibitor used to shrink the prostate gland, is admitted because of continuing benign prostate prostatic hypertrophy (BPH) symptoms when planning care. Which nursing problem should the nurse address first?
a. Chronic pain
b. Urinary retention
c. Risk for infection
d. Disturbed sleep pattern
3. An older client has been diagnosed with chronic venous insufficiency. To prevent venous return, which action should the nurse encourage the client to
a. Wear cotton socks and enclosed toe shoes whenever outside
b. Drink 8 to 10 ounces of water a day
c. Sit at the side of the bed for 15 minutes before standing
d. Lie down in bed 2 times a day
4. When caring for a client with a full thickness burn covering 40% of the body, the nurse observes pertinent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values?
a. Hematocrit
b Platelet count
c.White blood cell (WBC) count
d.Blood pH level
5. An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and
implant. During the immediate postoperative period, which intervention should the nurse implement
a. Provide an eye shield to be worn while sleeping@@@@@
b. Obtain vital signs every 2 hours during hospitalization
c. Encourage deep breathing and coughing exercises
d. Teach a family member to administer eye drops
6. After several days of coughing and taking acetaminophen to treat temperatures of 101 F (38. 3 C), a client with DI is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first?
a. Reassess vital signs
b. Obtain sputum for culture
c. Obtain a fingerstick glucose-good@@@@
d. Administer an antipyretic
7.a client takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory values should the nurse review?
a. Serum electrolytes
b. Complete blood count
c. Liver enzymes
d. Platelet count
8. The nurse is caring for a client post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement?
a. Administer IV fluid bolus as prescribed by the healthcare provider
b. Medicate for pain and monitor vital signs according to protocol
c. Encourage the client to splint the incision with a pillow to cough and deep breathe
d. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter
9. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fraction (ORIF). The nurse determines that the client’s distal pulses are diminished in the left foot. Which interventions should the nurse implement? (SATA)-good
a. Offer ice chips and oral clear liquids
Verify pedal pulses using a doppler pulse device@@@??
Monitor left leg for pain, pallor, paresthesia, paralysis, pressure@?> Evaluate the application of the splint to the left leg@?
e. Administer oral antispasmodics and narcotics analgesics
10. A nurse is caring for a client with Diabetes Insipidus (DI). which data warrants the most immediate intervention by the nurse?
a. Dry skin with inelastic turgor
b. Apical rate of 110 beats per minute
c. Polyuria and excessive thirst
d. Serum sodium of 185 mEq/L
11. The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
a. Platelet count @@@@
b. Red blood cell count
c. Hemoglobin levels
d. White blood cell count
12. A male client is admitted to the emergency department with vomiting of dark brown, foul- smelling emesis. He reports he had a surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first
● Insert a nasogastric tube (NGT) and attach to low intermittent suction
13. A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the healthcare provider?
a. Hematocrit
b. Blood glucose
c. Oxygen saturation
d. Troponin I@@@
14. A client is hospitalized after experiencing a myocardial infarction (MI) to reduce cardiac workload, which intervention should the nurse include in the client’s plan of care?
a. Teach to sleep in a side-lying position
b. Encourage active range of motion exercises
c. Provide a bedside commode for toileting?@@@
d. Assist with ambulation in the hallway
15. The healthcare provider prescribes radiation therapy (RT) for a client with terminal metastatic who is experiencing increased pain due to spinal compression. The client asks the nurse why radiation therapy is prescribed. Which mechanism supports the use of RT in the client’s metastatic cancer?
a. Implementation of all possible treatments offers clients the best chance of survival
b. Pain relief can be provided by shrinking tumors that press against spinal nerves@@@
c. Evidence indicates that RT can prolong life in clients with metastatic cancers
d. RT is an alternative to surgery that affects tumor growth and eradicates cancer
16. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a PUVA treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
a. Brown, rough, greasy, wart-like papules on the face
b. Thick skin plagues topped by silvery white scales prob not@@
c. Requires sunglasses because sunlight hurts eyes
d. Tenderness upon palpation and generalized erythema
17. An older client with long-term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse to determine if the patient with type 2 DM is experiencing long-term complications? (SATA)-good
a. visual acuity@@
b. Skin condition of lower extremities@@ Sensation in feet and legs@@
Serum creatinine and blood urea nitrogen (BUN)@@
e. Signs of respiratory tract infection
18. A client with a history of chronic obstructive disease (COPD) is admitted with pneumonia. Vital signs include oxygen saturation 89% temperature 100.5 F ( C) heart rate 120 beats/minute, respirations 28 breaths/minute and blood pressure 170/90mmHg. Which finding warrants immediate intervention by the nurse?
a. Shortness of breath on exertion
b. Coarse breath sounds
c. Bilateral diffuse wheezing
d. Yellow expectorated sputum
19. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP).
What is the best initial nursing action?-good
a. Increase the flow of the bladder irrigation
b. Measure the client’s intake and output
c. Administer a PRN dose of an antispasmodic agent
d. Provide additional oral fluid intake
20. The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon?-good
a. The fecal matter is brown and has a solid consistency
b. There are no bowel sounds in the left lower quadrant
c. The stoma mucosa is purple in color???
d. The stoma has streaks of bright red blood
21. The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?
a. Skull radiography
b. Computerized tomography (CT) scan
c. Magnetic resonance imaging (MRI)
d. Lumbar puncture
22. A young adult male client has a leg cast following an open reduction for fractured tibia. He is in skeletal traction with 10 lbs of weight. Approximately two hours after returning to the unit, he reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blunched. Which action should the nurse promote first?
a. Release the traction and notify the healthcare provider
b. Administer PRN pain medication routinely as prescribed
c. Notify the healthcare provider of the assessment findings
d. Record the observations and check the imb every 15 minutes.
23. A client is receiving combination chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic, side effects which assessment findings warrants intervention by the nurse?
a. Polycythemia
b. Leukopenia
c. Ascites
d. nystagmus
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