ATI RN ADULT MED SURG
PROCTORED EXAM 2023-2024 WITH
NGN
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure.
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Which assessment finding warrants immediate intervention by the nurse? - ANSIrregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis
of her fingers. After warming her hands, the fingers turn red and the client reports a
burning sensation. What action should the nurse take? - ANS-Continue to monitor the
fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is admitted with a right hip
fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with
diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which
intervention is most important for the nurse to implement first? - ANS-Administer PRN
oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for a
laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider prior to proceeding with the scheduled procedure?
- ANS-The client's blood pressure reading is 184/88 mm Hg
Following surgical repair of the bladder, a female client is being discharged from the
hospital to home with an indwelling urinary catheter. Which instruction is most important
for the nurse to provide to this client? - ANS-Keep the drainage bag lower than the level
of the bladder
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse? -
ANS-Further decline in level of consciousness
Which client has the highest risk for developing skin cancer? - ANS-A 65 year-old fairskinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most important
for the nurse to obtain? - ANS-Daily weight
A female 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 fixation (ORIF). The nurse determines that her distal pulses are
diminished in the left foot. Which interventions should the nurse implement? (Select all
that apply.) - ANS-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.
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action? - ANS-Observe the color, consistency,
and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and
diaphoretic. Which assessment is most important for the nurse to obtain? - ANS-Breath
sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first? - ANS-Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain? - ANS-Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which intervention should the nurse
implement? - ANS-Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened tenacious mucous, and the inability to walk up
a flight of stairs without experiencing breathlessness. Which action is most important for
the nurse to instruct the client about self-care? - ANS-Increase the daily intake of oral
fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and
? % proximal right coronary artery (RCA). The client later asks the nurse "what does all
this mean for me?" What information should the nurse provide? - ANS-Three main
arteries have major blockages, with only 1 to 5% of blood flow getting through to the
heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The
heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the
nurse administer? [Show Less]