ATI MEDSURG PROTECTED EXAM LATEST UPDATE
1. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the
following actions should the nurse take?
Loosen the knots on the ropes if the client is experiencing pain
Ensure the client's weights are hanging freely from the bed
Check the client's bony prominence every 12 hours
Cleanse the client's pin sites with povidone-iodine.
(correct answer)Ensure the client's weights are hanging freely from the bed
2. A nurse in a provider's office is reinforcing teaching with a client who has anemia & has been taking ferrous
gluconate for several weeks. Which of the following instructions should the nurse include?
Take this medications between meals.
Limit intake of Vitamin C while taking this medication.
Take this medication with milk.
Limit intake of whole grains while taking this medication
(correct answer)Take this medication between meals
3. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of
the following instructions should the nurse include in the teaching?
Empty the pouch immediately after meals.
Change the entire appliance once a day.
Limit fluid intake.
Avoid medications in capsule or enteric form.
(correct answer)Avoid medications in capsule or enteric form.
4. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous
gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse
include in the plan of care?
Measure abdominal girth daily.
Use sterile water to irrigate the nasogastric tube.term-3
,Maintain the client in Fowler's position.
Moisten the client's lips with lemon-glycerin swabs.
(correct answer)Maintain the client is Fowler's position
5. A nurse is reviewing the plan of caring for a client who has cellulitis of the leg. Which of the following interventions
should the nurse recommend?
Apply topical antifungal agents.
Apply fresh ice packs every 4 hrs.
Wash daily w/ an antibacterial soap.
Keep draining lesions uncovered to air dry.
(correct answer)Wash daily w/ an antibacterial soap.
6. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an
escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for
the nurse to make?
An escharotomy surgically removes dead tissue.
A cannula will be inserted into the bone to infuse fluids & antibiotics.
A piece of skin will be removed and grafted over the burned area.
Large incisions will be made in the burned tissue to improve circulation.
(correct answer)Large incisions will be made in the burned tissue to improve circulation.
7. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should
the nurse expect the client to report?
Decreased color perception
Loss of peripheral vision
Bright flashes of light
Eyestrain
(correct answer)Decreased color perception
, 8. A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile infection. Which of
the following information should the nurse include in the teaching?
Assign the client to a room with a negative air-flow system
Use alcohol-based hand sanitizer when leaving the clients room
Clean contaminated surfaces in the client's room with a phenol solution
Have family members wear a gown and gloves when visiting
(correct answer)Have family members wear a gown & gloves when visiting
9. A nurse is planning teaching for a group of adolescents who each recently has surgical placement of an ostomy.
Which of the following methods should the nurse use as a psychomotor approach to learning?
Role play
Group discussions
Question-answer meeting
Practice sessions
(correct answer)Practice sessions
10. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should
the nurse make?
Drink a cup of hot cocoa before bedtime.
Maintain a consistent time to wake up each day.
Exercise 1 hour before going to bed.
Watch a television program in bed before going to sleep.
(correct answer)Maintain a consistent time to wake up each day
11. The nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following
statements should the nurse identify as an indication that the client understands the use of this assistive device?
This type of hearing aid does not allow for fine-tuning of volume
I shouldn't have trouble keeping the hearing aid in place during exercise
I expect to hear a whistling sound when I first insert the hearing aid
I will be sure to remove my hearing aid before taking a shower
, (correct answer)I will be sure to remove my hearing aid before taking a shower
12. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system.
Which of the following actions should the nurse take first?
Rinse the feeding bad with water between feedings/
Tell the client to keep the head of the bed elevated at least 30 degres
Make sure the enteral formula is at room temperature
Wipe the tope of the formula can with alcohol
(correct answer)Tell the client to keep the head of the bed elevated at least 30 degrees
13. A nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following
actions should the nurse take?
Gently shake the container of medication prior to administration
Transfer the medication to a medicine cup
Place the client in a semi-Fowler's position prior to medication administration.
Verify the dosage by measuring the liquid before administering it.
(correct answer)Gently shake the container of medication prior to administration.
14. A nurse in a clinic is caring for a middle aged adult client who states "The doctor says that, since I am at an average
risk for colon cancer, I should have routine screening. What does the involve?" Which of the following responses
should the nurse make?
I'll get a blood sample from you and send it for a screening test.
Beginning at age 60, you should have a colonoscopy.
You should have a fecal occult blood test every year.
The recommendation is to have a sigmoidoscopy every 10 years.
(correct answer)You should have a fecal occult blood test every year.
15. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings
at the IV site should the nurse identify as indicating infiltration?
1. A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the
following actions should the nurse take?
Loosen the knots on the ropes if the client is experiencing pain
Ensure the client's weights are hanging freely from the bed
Check the client's bony prominence every 12 hours
Cleanse the client's pin sites with povidone-iodine.
(correct answer)Ensure the client's weights are hanging freely from the bed
2. A nurse in a provider's office is reinforcing teaching with a client who has anemia & has been taking ferrous
gluconate for several weeks. Which of the following instructions should the nurse include?
Take this medications between meals.
Limit intake of Vitamin C while taking this medication.
Take this medication with milk.
Limit intake of whole grains while taking this medication
(correct answer)Take this medication between meals
3. A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of
the following instructions should the nurse include in the teaching?
Empty the pouch immediately after meals.
Change the entire appliance once a day.
Limit fluid intake.
Avoid medications in capsule or enteric form.
(correct answer)Avoid medications in capsule or enteric form.
4. A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous
gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse
include in the plan of care?
Measure abdominal girth daily.
Use sterile water to irrigate the nasogastric tube.term-3
,Maintain the client in Fowler's position.
Moisten the client's lips with lemon-glycerin swabs.
(correct answer)Maintain the client is Fowler's position
5. A nurse is reviewing the plan of caring for a client who has cellulitis of the leg. Which of the following interventions
should the nurse recommend?
Apply topical antifungal agents.
Apply fresh ice packs every 4 hrs.
Wash daily w/ an antibacterial soap.
Keep draining lesions uncovered to air dry.
(correct answer)Wash daily w/ an antibacterial soap.
6. A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an
escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for
the nurse to make?
An escharotomy surgically removes dead tissue.
A cannula will be inserted into the bone to infuse fluids & antibiotics.
A piece of skin will be removed and grafted over the burned area.
Large incisions will be made in the burned tissue to improve circulation.
(correct answer)Large incisions will be made in the burned tissue to improve circulation.
7. A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should
the nurse expect the client to report?
Decreased color perception
Loss of peripheral vision
Bright flashes of light
Eyestrain
(correct answer)Decreased color perception
, 8. A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile infection. Which of
the following information should the nurse include in the teaching?
Assign the client to a room with a negative air-flow system
Use alcohol-based hand sanitizer when leaving the clients room
Clean contaminated surfaces in the client's room with a phenol solution
Have family members wear a gown and gloves when visiting
(correct answer)Have family members wear a gown & gloves when visiting
9. A nurse is planning teaching for a group of adolescents who each recently has surgical placement of an ostomy.
Which of the following methods should the nurse use as a psychomotor approach to learning?
Role play
Group discussions
Question-answer meeting
Practice sessions
(correct answer)Practice sessions
10. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should
the nurse make?
Drink a cup of hot cocoa before bedtime.
Maintain a consistent time to wake up each day.
Exercise 1 hour before going to bed.
Watch a television program in bed before going to sleep.
(correct answer)Maintain a consistent time to wake up each day
11. The nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following
statements should the nurse identify as an indication that the client understands the use of this assistive device?
This type of hearing aid does not allow for fine-tuning of volume
I shouldn't have trouble keeping the hearing aid in place during exercise
I expect to hear a whistling sound when I first insert the hearing aid
I will be sure to remove my hearing aid before taking a shower
, (correct answer)I will be sure to remove my hearing aid before taking a shower
12. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system.
Which of the following actions should the nurse take first?
Rinse the feeding bad with water between feedings/
Tell the client to keep the head of the bed elevated at least 30 degres
Make sure the enteral formula is at room temperature
Wipe the tope of the formula can with alcohol
(correct answer)Tell the client to keep the head of the bed elevated at least 30 degrees
13. A nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following
actions should the nurse take?
Gently shake the container of medication prior to administration
Transfer the medication to a medicine cup
Place the client in a semi-Fowler's position prior to medication administration.
Verify the dosage by measuring the liquid before administering it.
(correct answer)Gently shake the container of medication prior to administration.
14. A nurse in a clinic is caring for a middle aged adult client who states "The doctor says that, since I am at an average
risk for colon cancer, I should have routine screening. What does the involve?" Which of the following responses
should the nurse make?
I'll get a blood sample from you and send it for a screening test.
Beginning at age 60, you should have a colonoscopy.
You should have a fecal occult blood test every year.
The recommendation is to have a sigmoidoscopy every 10 years.
(correct answer)You should have a fecal occult blood test every year.
15. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings
at the IV site should the nurse identify as indicating infiltration?
