ATI PN MED SURG 2024 EXAM / ATI PN MEDICAL SURGICAL 2024 PROCTORED EXAM 180 QUESTIONS WITH DETAILED VERIFIED ANSWERS AND RATIONALES /A+ GRADE ASSURED
... [Show More]
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.
--------------------
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.
------------------
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 self examination. 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.
----------------------
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.
--------------------------
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.
--------------------------
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.
---------------------------
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.
--------------------------
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.
---------------------
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.
--------------------------
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 contact with large groups of people."
Rationale:
Glucocorticoids cause immunosuppression and can mask infection. The client should limit contact with sources of possible infections, such as large groups of people.
------------------------
The client should take glucocorticoids with food to prevent gastrointestinal upset and bleeding.
Clients who take glucocorticoids are at risk for osteoporosis, so they should take additional vitamin D and calcium supplements.
t is not necessary for a client who has SLE and is taking a glucocorticoid to restrict protein intake.
A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? - ....ANSWER...Decrease pain during urination.
Rationale:
Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.
-------------------------
Bacteria in the urinary tract is reduced with the use of an antimicrobial medication, such as fosfomycin.
The urge to void is suppressed with the use of an antispasmodic for urinary incontinence, such as oxybutynin.
Nerve stimulation to the bladder muscle is prevented with the use of an antispasmodic, such as hyoscyamine.
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swallowing at the IV site. In which order should the nurse perform the following steps? Move the step in order. - ....ANSWER...Check the IV site is the first step. The first action the nurse should take when using the nursing process is to check the IV site for infiltration.
Stop the infusion is the second step. If infiltration is found, the next step the nurse should take is to stop the infusion to prevent vein and tissue damage.
Withdraw the IV catheter is the third step. Once the infusion is stopped, the nurse should remove the IV catheter.
Elevate the affected arm is the fourth step. The nurse should elevate the affected extremity to decrease swelling.
Notify the charge nurse is the fifth step. The nurse should notify the charge nurse about the client's condition.
A nurse is monitoring a client who has a history of an enlarged prostate experiencing suprapubic discomfort. Which of the following actions should the nurse take first? - ....ANSWER...Palpate the abdomen.
Rationale:
When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.
A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? - ....ANSWER..."You should have a pneumococcal immunization every 10 years."
Rationale:
The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia.
-------------------
The nurse should remind the client to have a screening for glaucoma every 2 to 3 years along with an annual visual acuity examination.
The nurse should remind the client to have a physical examination every year. The nurse should remind the client to have their hearing checked every year.
A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? - ....ANSWER...Initiate oxygen at 4L/min via nasal cannula.
Rationale:
The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia.
---------------------------
The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first.
The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first.
The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first.
A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? - ....ANSWER...Mask
Rationale:
The nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client.
A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? - ....ANSWER...Cetriaxone
Rationale:
Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription.
--------------------
The nurse should administer diltiazem because the client's heart rate and blood pressure are within the expected reference ranges.
The nurse should administer pioglitazone because the client's blood glucose level is within the expected reference range.
The nurse should administer hydrocodone and acetaminophen to manage the client's pain because the client's respiratory rate is within the expected reference range.
A nurse is caring for a client who is 3 days postoperative following a total hip athroplasty. Which of the following actions should the nurse take? - ....ANSWER...Maintain abduction of the client's right leg while in bed.
Rationale:
The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.
------------------
The nurse should instruct the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight.
A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? - ....ANSWER...Rephrase client instructions when not understood.
Rationale:
When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.
When communicating with a client who has hearing loss, the nurse should keep their hands away from their mouth to promote lip reading.
When communicating with a client who has hearing loss, the nurse should speak in a normal tone of voice. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants.
When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading.
A nurse is caring for a client who is postoperative and has portable wound bulb suction device. Which of the following actions should the nurse take? - ....ANSWER...Compress the bulb reservoir and then close the drainage valve.
Rationale:
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 portable wound bulb suction device.
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamplet? - ....ANSWER...Females have a higher risk for contracting STIs than males.
Rationale:
The nurse should include that oral contraceptive use, prolonged contact with male secretions, and increased cervical permeability during hormone fluctuations increase a female's risk for acquiring STIs.
A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client? - ....ANSWER...Speech-language pathologist
Rationale:
The nurse should recommend a referral for a speech-language pathologist to evaluate the client's ability to safely swallow. A client who had a stroke is at increased risk for dysphagia and aspiration of fluids, food, and medications. The speech-language pathologist should conduct a swallowing study to determine the client's risk for aspiration and provide teaching to the client regarding swallowing techniques.
A nurse is caring for a client who is postoperative following an above-the-knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take? - ....ANSWER...Collaborative with the physical therapist to initiate alternative pain therapies.
Rationale:
Phantom limb pain does not usually respond to routine postoperative analgesia. The nurse should collaborate with the physical therapist to initiate alternative pain therapies, such as heat, massage, and transcutaneous electrical nerve stimulation.
A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching? - ....ANSWER..."Add oily fish to your diet twice weekly".
Rationale:
The nurse should reinforce teaching about dietary changes to manage coronary artery disease, such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice per week.
A nurse is reinforcing discharge teaching with a client who has mechanical mitral valve replacement. Which of the following statements by the client indicated an understanding of the teaching? - ....ANSWER..."I will notify my dentist about this procedure."
Rationale:
The nurse should instruct the client to notify their dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk for endocardial infection.
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing myocardial infarction? - ....ANSWER...Elevated troponin.
Rationale:
Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication that the client is experiencing a myocardial infarction.
A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching? - ....ANSWER...1 cup of boiled broccoli
Rationale:
The nurse should recommend boiled broccoli to the client because 1 cup contains 115 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? - ....ANSWER...Keep bed linens off of the affected areas.
Rationale:
The nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions.
-------
The nurse should apply cool compresses to help relieve pain caused by the lesions.
The nurse should initiate airborne and contact precautions for a client who is immunocompromised and has widespread herpes zoster lesions. Otherwise, the nurse should follow standard precautions.
A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescription should the nurse expect to administer when the client reports pain? - ....ANSWER...Acetaminophen
Rationale:
Acetaminophen is a nonopioid analgesic that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics. However, clients should be advised that acetaminophen toxicity can cause liver damage.
Etanercept treats rheumatoid arthritis
Methotrexate treats rheumatoid arthritis
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? - ....ANSWER...HbA1c results measure glucose control for the prior 3 months.
Rationale:
HbA1c testing reflects average overall glucose control over a 3-month period. The nurse should inform the client that HbA1c testing is the best measure of long-term glucose control.
----------------
An HbA1c level of 9.5% to 10% represents ineffective diabetic control and requires intervention. The expected reference range of HbA1c is 4% to 5.9% with a level of 7% representing effective diabetic control.
An elevated HbA1c level above the expected reference range of 7% indicates ineffective glucose control.
HbA1c testing measures glucose control over time and should not be used to diagnose diabetes mellitus. A glucose tolerance test and a fasting blood glucose test are used to diagnose diabetes mellitus.
A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease? - ....ANSWER...Diabete mellitus
Rationale:
Clients who have diabetes mellitus are at increased risk for developing cardiovascular and peripheral vascular disease because of the changes in the microvasculature resulting from elevated levels of glucose.
myasthenia gravis are at increased risk for pneumonia due to aspiration resulting from muscle weakness.
Clients who have rheumatoid arthritis are at increased risk for iron deficiency anemia.
Clients who have Crohn's disease are at increased risk for malabsorption, malnutrition, and eventually colon cancer resulting from repeated damage to the intestinal mucosa.
A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? - ....ANSWER..."You should plave your toothbrush in hydrogen peroxide."
Rationale:
Clients who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection.
A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? - ....ANSWER..."Provide the client with disposable utensils and dishes for meals" is correct.
Clients who have C. difficile require contact precautions, which include using disposable utensils and dishes during meals to prevent exposure to contaminants by others.
"Leave blood pressure equipment in the client's room" is correct. When using contact precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen.
"Clean contaminated surfaces with a bleach solution" is correct. The health care staff should use a bleach solution to clean equipment to prevent transmission of the pathogen.
"Use an alcohol-based hand sanitizer after client care" is incorrect. The nurse should instruct the AP to cleanse their hands with soap and water prior to and following client contact. Alcohol-based solutions do not kill C. difficile spores.
"Wear a face mask when in the client's room" is incorrect. It is not necessary for health care staff to use a face mask when caring for a client who has C. difficile because the infection is spread by contact.
"Provide the client with disposable utensils and dishes for meals" is correct. Clients who have C. difficile require contact precautions, which include using disposable utensils and dishes during meals to prevent exposure to contaminants by others."Leave blood pressure equipment in the client's room" is correct. When using contact precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen."Clean contaminated surfaces with a bleach solution" is correct. The health care staff should use a bleach solution to clean equipment to prevent transmission of the pathogen."Use an alcohol-based hand sanitizer after client care" is incorrect. The nurse should instruct the AP to cleanse their hands wit
A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging? - ....ANSWER..."My food tastes bland even after I add seasoning.
Rationale:
As clients age, there is a decrease in the number of taste buds of the tongue due to tongue atrophy.
A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (Select the hot spots) - ....ANSWER...A (Frontal lobe)
Rationale: [Show Less]