ATI MED SURG PROCTORED EXAM GUIDE 2020/2021
1. The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for
the nurse to follow-up?
1. Fetal heart rate of 130 to 140 beats/min.
2. Fundal level at 3 fingers below the umbilicus.
3. Fetal movements felt faintly on lower part of abdomen.
4. Client reports backache and leg cramps when sleeping.
2. The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use
to reduce the risk of malpractice litigation? (Select all that apply.)
1. Ask the charge nurse to reassign the client to a different nurse.
2. Notify the health care provider of the medication error immediately.
3. Report the incident to the manager for appropriate follow-up with the client.
4. Print a copy of the incident report to keep in the nurse’s personal records.
5. Explain to the client that the nurse has a heavier assignment than normal.
3. The nurse provides care for a client who is receiving sitagliptin for type 2 diabetes mellitus.
Which assessment finding causes the nurse to suspect the client is experiencing an adverse reaction
to the medication?
1. Weight gain.
2. Anemia.
3. Abdominal pain.
4. Edema.
4. The nurse orients a new nurse who inquired about electrical cardioversion. Which statement
about cardioversion by the nurse is accurate? (Select all that apply.)
1. “Cardioversion is used to treat ventricular fibrillation.”
2. “Pulseless electrical activity (PEA) responds to
cardioversion.” 3. “Cardioversion treats atrial fibrillation and
atrial flutter.”
4. “An intravenous sedative is required in elective
cardioversion.” 5. “Check for life-threatening dysrhythmia during
cardioversion.”
5. A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse
teaches the client about the prevention of future foot wounds. Which client statement indicates
the teaching is effective? (Select all that apply.)
1. “I should not cross my legs.”
2. “I should wear shoes only when I go outside.”
3. “I should apply lotion between my toes after a shower.”
4. “I should inspect the inside of my shoes before I put them on.”
5. “I should use a mirror to examine the bottom of my feet every day.”
6. The nurse prepares discharge instructions for a client who speaks very little English and is
recovering from an emergency appendectomy. Which nursing action best helps this client understand
wound care instructions?
1. Asking if the client understands the instruction.
2. Demonstrating the procedure and having the client return the demonstration.
3. Asking an interpreter to replay the instructions to the client.
4. Writing out the instructions and having a family member read them to the client.
,7. The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for
the nurse to implement? (Select all that apply.)
1.Teach family members about physical signs of impending death.
2. Encourage the management of adverse signs and symptoms.
3. Assess family coping mechanisms to handle impending loss.
4. Avoid spirituality as nurse’s beliefs may not be congruent with the client’s.
5. Leave the family alone as there is no more need for direct nursing care.
8. The nurse performs an intermittent urinary catheterization for a client who is 2 hours post
surgery. Which client observation indicates that the procedure was effective?
1. Reports dribbling of
urine. 2. Rests quietly.
3. Notes distention above symphysis pubis.
4. Voids 30 mL every 15 minutes.
9. The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client.
Which action does the nurse emphasize when giving these directions?
1. Warm the lotion in the microwave before use.
2. Wear clean gloves while performing the massage.
3. Place the bed in the lowest position after the massage.
4. Start the massage at the shoulders and work toward the buttocks.
10. The nurse observes a student nurse provide a client with a subcutaneous injection of heparin.
For which student action will the nurse intervene? (Select all that apply.)
1. Pinches the skin and inserts the needle 90 degrees.
2. Places the needle in the sharps container.
3. Administers the injection 1/2 inch from the
umbilicus. 4. Aspirates after inserting the needle.
5. Massages the site.
11. The nurse provides care to a client who experienced prolonged cold exposure. For
which complication does the nurse closely monitor this client?
1. Ventricular fibrillation.
2. Hypertension.
3. Metabolic alkalosis.
4. Shivering.
12. The nurse provides care for clients in a headache clinic. Which client should the nurse assess first?
1. The client reporting pain and neck stiffness.
2. The client reporting abdominal pain and vomiting.
3. The client with difficulty speaking to the receptionist.
4. The client with a headache of 3 weeks’ duration.
13. The nurse is discussing infection control guidelines with a group of student nurses.
Which information is most important for the nurse to include in the discussion?
1. “A gown should be worn when measuring the blood pressure of a client with
a methicillin-resistant Staphylococcus aureus (MRSA) wound infection.”
, 2. “The door should be kept closed to the room of a client with a clostridium difficile
(C. diff) infection.”
3. “Disposable dishes should be provided for a client with a hepatitis B infection.”
4. “A surgical mask should be worn when providing care for a client with
pulmonary tuberculosis.”
14. The nurse uses a paper-based documentation system to write a client care note. The previous
nurse’s documentation appears incomplete. Which action should the nurse take next?
1. Draw a line through any empty space and continue documenting.
2. Mark out the previous nurse’s entry, initial, and continue documenting.
3. Complete an incident report for the nurse manager to review.
4. Call the previous nurse at home and ask if the documented entry is complete.
15. While preparing medications, the nurse documents that a client is allergic to penicillin.
Which medication will the nurse question before administering to this client?
1. Cefazolin.
2. Doxycycline.
3. Ciprofloxacin.
4. Clarithromycin.
16. The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom
should the nurse immediately report to the healthcare provider?
1. Cyanosis of the tongue.
2. Jaundiced skin.
3. Slurred speech.
4. Slow capillary refill.
17. The nurse develops a teaching plan to promote optimal cardiac output during pregnancy.
Which information is most important for the nurse include?
1. Take frequent rest periods between activities.
2. Modify aerobic exercise as pregnancy
progresses. 3. Avoid resting or sleeping in the supine
position.
4. Elevate both lower extremities whenever sitting.
18. The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to
the LPN/LVN to provide care?
1. Client with a brain natriuretic peptide (BNP) level of 300
pg/mL. 2. Client with an erythrocyte sedimentation rate of 10
mm/h.
3. Client with a C-reactive protein (CRP) level of 4 mg/L.
4. Client with an international normalized ratio (INR) level of 8.0.
19. The nurse provides care to a client of Native American descent who has traditional beliefs
about health and illness. Which action is most appropriate for the nurse to take?
1. Ask if cultural healers should be contacted.
2. Avoid asking questions unless initiated by the client.
3. Obtain further information about the client’s cultural beliefs from the family.
4. Explain the usual hospital routines for mealtimes, care, and family visits.
1. The nurse assess a client who is in the 24th week of gestation. Which finding is a priority for
the nurse to follow-up?
1. Fetal heart rate of 130 to 140 beats/min.
2. Fundal level at 3 fingers below the umbilicus.
3. Fetal movements felt faintly on lower part of abdomen.
4. Client reports backache and leg cramps when sleeping.
2. The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use
to reduce the risk of malpractice litigation? (Select all that apply.)
1. Ask the charge nurse to reassign the client to a different nurse.
2. Notify the health care provider of the medication error immediately.
3. Report the incident to the manager for appropriate follow-up with the client.
4. Print a copy of the incident report to keep in the nurse’s personal records.
5. Explain to the client that the nurse has a heavier assignment than normal.
3. The nurse provides care for a client who is receiving sitagliptin for type 2 diabetes mellitus.
Which assessment finding causes the nurse to suspect the client is experiencing an adverse reaction
to the medication?
1. Weight gain.
2. Anemia.
3. Abdominal pain.
4. Edema.
4. The nurse orients a new nurse who inquired about electrical cardioversion. Which statement
about cardioversion by the nurse is accurate? (Select all that apply.)
1. “Cardioversion is used to treat ventricular fibrillation.”
2. “Pulseless electrical activity (PEA) responds to
cardioversion.” 3. “Cardioversion treats atrial fibrillation and
atrial flutter.”
4. “An intravenous sedative is required in elective
cardioversion.” 5. “Check for life-threatening dysrhythmia during
cardioversion.”
5. A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse
teaches the client about the prevention of future foot wounds. Which client statement indicates
the teaching is effective? (Select all that apply.)
1. “I should not cross my legs.”
2. “I should wear shoes only when I go outside.”
3. “I should apply lotion between my toes after a shower.”
4. “I should inspect the inside of my shoes before I put them on.”
5. “I should use a mirror to examine the bottom of my feet every day.”
6. The nurse prepares discharge instructions for a client who speaks very little English and is
recovering from an emergency appendectomy. Which nursing action best helps this client understand
wound care instructions?
1. Asking if the client understands the instruction.
2. Demonstrating the procedure and having the client return the demonstration.
3. Asking an interpreter to replay the instructions to the client.
4. Writing out the instructions and having a family member read them to the client.
,7. The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for
the nurse to implement? (Select all that apply.)
1.Teach family members about physical signs of impending death.
2. Encourage the management of adverse signs and symptoms.
3. Assess family coping mechanisms to handle impending loss.
4. Avoid spirituality as nurse’s beliefs may not be congruent with the client’s.
5. Leave the family alone as there is no more need for direct nursing care.
8. The nurse performs an intermittent urinary catheterization for a client who is 2 hours post
surgery. Which client observation indicates that the procedure was effective?
1. Reports dribbling of
urine. 2. Rests quietly.
3. Notes distention above symphysis pubis.
4. Voids 30 mL every 15 minutes.
9. The nurse directs the nursing assistive personnel (NAP) to provide a back massage to a client.
Which action does the nurse emphasize when giving these directions?
1. Warm the lotion in the microwave before use.
2. Wear clean gloves while performing the massage.
3. Place the bed in the lowest position after the massage.
4. Start the massage at the shoulders and work toward the buttocks.
10. The nurse observes a student nurse provide a client with a subcutaneous injection of heparin.
For which student action will the nurse intervene? (Select all that apply.)
1. Pinches the skin and inserts the needle 90 degrees.
2. Places the needle in the sharps container.
3. Administers the injection 1/2 inch from the
umbilicus. 4. Aspirates after inserting the needle.
5. Massages the site.
11. The nurse provides care to a client who experienced prolonged cold exposure. For
which complication does the nurse closely monitor this client?
1. Ventricular fibrillation.
2. Hypertension.
3. Metabolic alkalosis.
4. Shivering.
12. The nurse provides care for clients in a headache clinic. Which client should the nurse assess first?
1. The client reporting pain and neck stiffness.
2. The client reporting abdominal pain and vomiting.
3. The client with difficulty speaking to the receptionist.
4. The client with a headache of 3 weeks’ duration.
13. The nurse is discussing infection control guidelines with a group of student nurses.
Which information is most important for the nurse to include in the discussion?
1. “A gown should be worn when measuring the blood pressure of a client with
a methicillin-resistant Staphylococcus aureus (MRSA) wound infection.”
, 2. “The door should be kept closed to the room of a client with a clostridium difficile
(C. diff) infection.”
3. “Disposable dishes should be provided for a client with a hepatitis B infection.”
4. “A surgical mask should be worn when providing care for a client with
pulmonary tuberculosis.”
14. The nurse uses a paper-based documentation system to write a client care note. The previous
nurse’s documentation appears incomplete. Which action should the nurse take next?
1. Draw a line through any empty space and continue documenting.
2. Mark out the previous nurse’s entry, initial, and continue documenting.
3. Complete an incident report for the nurse manager to review.
4. Call the previous nurse at home and ask if the documented entry is complete.
15. While preparing medications, the nurse documents that a client is allergic to penicillin.
Which medication will the nurse question before administering to this client?
1. Cefazolin.
2. Doxycycline.
3. Ciprofloxacin.
4. Clarithromycin.
16. The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom
should the nurse immediately report to the healthcare provider?
1. Cyanosis of the tongue.
2. Jaundiced skin.
3. Slurred speech.
4. Slow capillary refill.
17. The nurse develops a teaching plan to promote optimal cardiac output during pregnancy.
Which information is most important for the nurse include?
1. Take frequent rest periods between activities.
2. Modify aerobic exercise as pregnancy
progresses. 3. Avoid resting or sleeping in the supine
position.
4. Elevate both lower extremities whenever sitting.
18. The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to
the LPN/LVN to provide care?
1. Client with a brain natriuretic peptide (BNP) level of 300
pg/mL. 2. Client with an erythrocyte sedimentation rate of 10
mm/h.
3. Client with a C-reactive protein (CRP) level of 4 mg/L.
4. Client with an international normalized ratio (INR) level of 8.0.
19. The nurse provides care to a client of Native American descent who has traditional beliefs
about health and illness. Which action is most appropriate for the nurse to take?
1. Ask if cultural healers should be contacted.
2. Avoid asking questions unless initiated by the client.
3. Obtain further information about the client’s cultural beliefs from the family.
4. Explain the usual hospital routines for mealtimes, care, and family visits.
