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ATI Med-Surg proctored Exam
- A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.
Answer: A. Take temperature once a day - A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client’s secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Relubricate the suction catheter tip with sterile saline when suctioning the airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer: A. Provide humidified oxygen - Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort?
A. Rub the client’s feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client’s oral fluid intake.
D. Place a moist heating pad under the client’s feet.
Answer: B. Obtain a pair of slipper socks for the client - A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale
Answer: C. Thick, red-colored urine - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
Answer: A. Shivering - A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will carry a complex carbohydrate snack with me when I exercise.”
B. “I should exercise first thing in the morning before eating breakfast.”
C. “I should avoid injecting insulin into my thigh if I am going to go running.”
D. “I will not exercise if my urine is positive for ketones.”
Answer: D. “I will not exercise if my urine is positive for ketones.” - A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?
A. Cover the client’s wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client’s vital signs.
D. Inform the client about the need to return to surgery
Answer: A. Cover the client’s wound with a moist, sterile dressing - A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia
Answer: B. Hyperventilation - A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D. Seeing flashes of light is an expected finding following extraction.
Answer: A. Avoid bending at the waist - A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
A. Suggest that the client rests before eating the meal.
B. Request a dietary consult.
C. Check the client’s vital signs.
D. Request an order for an antiemetic.
Answer: C. Check the client’s vital signs - A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client’s wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?
A. Sanguineous
B. Serous
C. Serosanguineous
D. Purulent
Answer: D. Purulent - A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications, which of the following actions should be reinforced during the teaching?
A. Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
B. Place the client’s affected leg into the CPM machine with the machine in the flexed position.
C. Place the client into a high Fowler’s position when initiating the CPM exercises.
D. Align the joints of the CPM machine with the knee gatch in the client’s bed.
Answer: A. Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. - A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)
A. Dyspnea
B. Barrel chest
C. Clubbing of the fingers
D. Shallow respirations
E. Bradycardia
Answer: A, B, C and D - A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of the client’s right nostril. Which of the following actions should the nurse take first?
A. Take the client’s temperature.
B. Place a dressing under the client’s nose.
C. Notify the charge nurse.
D. Test the drainage for glucose.
Answer: D. Test the drainage for glucose - A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A. Monitor for elevated blood pressure.
B. Provide analgesia for headaches.
C. Prevent bladder distention.
D. Elevate the client’s head.
Answer: C. Prevent bladder distention
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