ATI RN MED SURG PROCTORED EXAM (14 VERSIONS) / RN MED SURG ATI PROCTORED EXAM (14 VERSIONS): LATEST-2021, 100 % CORRECT

2021

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(14 DIFFERENT VERSIONS)




ATI
ATI RN MED SURGE PROCTORED EXAM

, ATI RN MED SURGE PROCTORED EXAM

VERSION 1
A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of
the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to
replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a
headache.

Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a
hematoma at the insertion site because this can indicate bleeding.

Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.

Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or
more to reduce the risk for a headache.

Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for
this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to
take hydroxyzine preoperatively. Which of the following effects of the medication should the
nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles

,INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.

Controlling emesis is correct. The nurse should include that hydroxyzine is an effective
antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.

Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as
diazepam (Valium), are used to produce skeletal muscle relaxation.

Preventing surgical site infections is incorrect. The nurse should instruct the client that
antibiotics administered prior to surgery are used to diminish the risk of surgical site infections;
hydroxyzine, an antiemetic, does not have any effect on bacteria.

Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the
effects of narcotic pain medications. The nurse should instruct the client that when it is used for
surgical clients, narcotic requirements may be significantly reduced.


. A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.

Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib
cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.

, Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity,
which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.

Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.

Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less
oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of
cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the
shoulders, is a common manifestation of Cushing's syndrome.Purple striations is
correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common
manifestation of Cushing's syndrome. This is due to the collection of body fat in these
areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome.
Clients who have this manifestation present with a round, red, full face.Tremors is
incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is
incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen,
with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.