ATI PN MED SURG 2024 EXAM / ATI PN
MEDICAL SURGICAL 2024 PROCTORED EXAM
180 QUESTIONS WITH DETAILED VERIFIED
ANSWERS AND RATIONALES /A+ GRADE
... [Show More]
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 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.
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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.
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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.
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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.
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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.
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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.
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The nurse should not apply any type of traction boot or allow the client's leg to rotate
internally or externally because it can cause a dislocation of the affected hip.
The nurse should provide a chair that does not allow the client to recline because a
reclining chair increases the risk of the client flexing at the hips beyond 90° when
moving to a standing position.
The nurse should encourage the client to stand at the bedside on the day of surgery
and, if prescribed by the provider, to walk using a walker. Passive range-of-motion
exercises require flexion and extension of the joints and are not recommended 3
days following surgery [Show Less]