ATI PN MED SURG 2024 EXAM / ATI PN
MEDICAL SURGICAL 2024 PROCTORED EXAM
180 QUESTIONS WITH DETAILED VERIFIED
ANSWERS AND RATIONALES /A+ GRADE
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ASSURED
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty.
The client exhibiting hypotension, tachycardia, and tachypnea. The nurse should
recognize that these findings indicate which of the following complications? -
....ANSWER...Pulmonary embolism.
Rationale:
Manifestations of a pulmonary embolism include hypotension, tachycardia, and
tachypnea.
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Manifestations of a wound infection include fever, inflammation of the incision, and
foul-smelling drainage. Hypotension, tachycardia, and tachypnea do not indicate a
wound infection in a client who is 1 day postoperative.
Thrombophlebitis is the inflammation of a blood vessel, which can lead to a
thrombus formation. Hypotension, tachycardia, and tachypnea do not indicate
thrombophlebitis.
Paralytic ileus is the absence of bowel peristalsis, or movement. Hypotension,
tachycardia, and tachypnea do not indicate a paralytic ileus.
A nurse is caring for a client who has an area indicating potential breakdown over
the sacrum. Which of the following actions should the nurse take? -
....ANSWER...Minimize the time the head of the bed is elevated.
Rationale:
The nurse should minimize the time the head of the bed is elevated to reduce
pressure on the sacral area.
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The nurse should collect further data before determining what type of dressing is
needed. For a stage 1 pressure injury, skin preparation can be applied to preserve
the integrity of the skin and prevent further direct injury. Alternatively, a dressing
such as a hydrocolloid or transparent dressing can be applied. However, gauze
dressings are not used in the treatment of a stage 1 pressure injury.
The nurse should not massage nor apply moisturizing lotion to an area indicating
potential breakdown because it can cause further skin injury.
The nurse should not place a donut-shaped cushion under the client's sacral area
because it can contribute to the development of a pressure injury.
A nurse is reinforcing teaching with an adolescent client regarding testicular selfexamination. Which of the following statements by the client demonstrates an
understanding of the teaching? - ....ANSWER..."I understand that testicular cancer is
typically painless."
Rationale:
Clients should report a lump that is not painful because testicular cancer is typically
painless.
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Clients should perform a testicular self-examination after a warm shower.
Clients should perform a testicular self-examination monthly.
Clients should report pea-sized lumps in the testes to a provider.
A nurse is preparing intermittent urinary catheterization for a female client who has
been unable to void following surgery 6 hr ago. Which of the following catheters
should the nurse use to perfrom this procedure? - ....ANSWER...Choice B
(A purple tip tube )
Rationale: This is an intermittent straight catheter and is the correct catheter for the
nurse to use.
A nurse is collecting data from a client who has hypothyroidism. Which of the
following manifestations should the nurse anticipate? - ....ANSWER...Bradycardia
Rationale:
The nurse should identify that bradycardia is a manifestation of hypothyroidism that
is caused by a decrease in the client's metabolic rate.
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Blurred vision is a manifestation of hyperthyroidism.
The nurse should identify that insomnia is a manifestation of hyperthyroidism that is
caused by an increase in the client's metabolic rate.
The nurse should identify that weight loss is a manifestation of hyperthyroidism
caused by an increase in the client's metabolic rate.
A home health nurse is reinforcing teaching about preventing asthma attacks with a
client who has asthma. Which of the following instructions should the nurse include
in the teaching? - ....ANSWER..."Do not allow visitors to smoke cigarettes in your
home."
Rationale:
The nurse should inform the client that cigarette smoke is a common allergen that
can increase the risk for triggering an asthma attack. Therefore, the client should not
allow anyone to smoke cigarettes in their home.
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The nurse should inform the client that carpet can hold mites and dust, which
increases the risk for triggering an asthma attack.
The nurse should inform the client that breathing cold air can cause bronchial
constriction, which increases the risk for triggering an asthma attack.
The nurse should inform the client that opening their windows during spring can
increase their exposure to environmental allergens, which increases the risk for
triggering an asthma attack.
A nurse is caring for a client who has a compound fracture of the femur and was
placed in balanced suspension skeletal traction 4 days ago. Which of the following
actions should the nurse take? - ....ANSWER...Perform pin site care daily.
Rationale:
The nurse should perform pin site care daily with chlorhexidine solution or use a
solution according to facility protocol. The nurse should also monitor the pin sites for
manifestations of infection.
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The nurse should ensure the client has an overbed trapeze to aid in lifting the upper
body off the bed when necessary and to help prevent skin breakdown of the heels
and elbows with client repositioning.
The nurse should identify that balanced suspension skeletal traction is managed
through the use of pins, pulleys, weights, and frames and that the client does not
wear a boot.
The nurse should ensure the weights hang freely at all times.
A nurse is reinforcing teaching with a client who has gonorrhea. Which of the
following information should the nurse include? - ....ANSWER..."You are at risk for
infertility with this infection, regardless of treatment."
Rationale:
The nurse should inform the client that there is a risk for infertility as a result of this
infection.
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The nurse should inform the client that sexual partners will require treatment to
prevent the risk for reoccurrence of the infection.
The nurse should instruct the client to abstain from sexual contact until treatment is
completed and cultures are negative.
The nurse should inform the client that immunity does not occur with this infection
and that reoccurrence is possible.
A nurse is caring for a client who has difficulty swallowing. Which of the following
actions should the nurse implement to prevent aspirtation? - ....ANSWER...Give the
client liquids with increased viscosity.
Rationale:
Thickened liquids are easier for the client to swallow and can prevent aspiration.
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Providing small, frequent meals can improve the client's nutritional intake, but it does
not decrease the risk for aspiration.
The client should tilt their neck forward while swallowing to decrease the risk for
aspiration.
Mouth care can enhance the client's sense of taste, but it does not decrease the risk
for aspiration.
A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with
a client. Which of the following statements by the client indicated an understanding
of the teaching? - ....ANSWER..."I should wait at least 2 hrs after eating before going
to bed."
Rationale:
The client should wait to lie down or go to bed at least 2 hr after eating to minimize
reflux.
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The client should eat four to six small meals per day rather than three large meals to
minimize bloating and abdominal distention.
The client should avoid spicy foods, including garlic, to minimize reflux.
The client should avoid drinking through a straw, which can promote belching and
reflux.
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus
(SLE) and is to begin taking methylpredniolone orally. Which of the following
statements should the nurse include in the teaching? - ....ANSWER..."Limit contac [Show Less]