2022 ATI RN MEDICAL-SURGICAL PROCTORED COMPLETE SOLUTION EXAM
FOR A STUDENT
A client with peptic ulcer disease has a new NG tube in place with orders for NG tube
monitoring for the nurse. What is an expected finding? - scant blood may be seen for
the first 12-24 hrs
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion.
Which of the following events should the nurse recognize as contaminating the field
(Select all that apply)
A. provider drops a sterile instrument onto the near side of the sterile field
B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field
C. procedure is delayed 1hr because the provider receives an emergency call
D. nurse turns to speak to someone who enters through the door behind the nurse
E. clients hand brushes against the outer edge of the sterile field - B, C, D
A nurse has removed a sterile pack from its outside cover and place it on a clean work
surface in preparation for an invasive procedure. Which of the following flaps should the
nurse unfold first:
A. closest to body
B. right side
C. left side
D. farthest from body - D
A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the
following objects can the nurse touch without breaking sterile technique (Select all that
apply)
A. bottle containing sterile solution
B. edge of sterile drape at the base of the field
C. inner wrapping of an item on the sterile field
D. irrigation syringe on the sterile field
E. one gloved hand with the other gloved hand - C, D, E
A pt comes to the hospital with a TB induration of 10mm what would be your following
nursing action? - obtain sputum cultures
A pt has a positive TB skin test what would your first action be? - put a mask on either
the pt or yourself
ACE inhibitors side effects: - A: angioedema
C: cough
E: elevated K+
,Acute hemolytic transfusion reaction s/s: - -chills
-fever
-low back pain
-tachycardia
-flushing
-hypotension
-chest tightening/pain
-tachypnea
-nausea
-anxiety
-hemoglobinuria
Anaphylactic transfusion reaction s/s: - -wheezing
-dyspnea
-chest tightness
-cyanosis
-hypotension
Appropriate oropharyngeal suctioning; select all: - -encourage pt to deep breath &
cough prior
-monitor O2 sats
-store catheter in clean dry place for use
-perform care 3 times a day (Q 8hrs)
Asthma & dry powder inhaler teaching: - breath in forcefully
Automated external defibrillator steps: - 1. turn it on & place pads on client
2. make sure no one is touching client
3. hit analyze
4. if shock is needed, AED will do it
AV block - AV block
Before an Endoscopy (EGD): - -NPO 6-8 hr
-remove dentures
Bilateral limb involvement occurs, making walking/balancing difficult. Which stage of
Parkinson's? - Stage 2
brady - brady
Caring for a client following a stroke of the right side with left-sided hemipalegia: - -
thicken liquids/foods
-high fowlers
-speech therapist for helping w/eating & speech
-monitor gag reflex/swallowing abilities
, -have suction equipment available
-occupational therapy
-support left arm with pillows, slings, etc
Caring for a client who has pancreatitis: - -keep NPO
-NG tube to suction gastric contents
-low fat, high protein, high carb diet
Risk factors:
-high fat diet
-excessive alcohol consumption
-age
Central venous access device care: - -remove tubing & solution bag every 24 hr
-DO NOT use line for other bolus IV solutions
-sterile dressing changes
-check cap glucose Q 4-6 hr
Client care following a thyroidectomy: - -High fowler's
-support head & neck w/pillows
-avoid neck extension
-check surgical dressing & back of neck for bleeding
-have trach supplies available
-coughing & deep breathing
-check for laryngeal damage by asking client to speak when awake from anesthesia
-admin pain meds
-tingling of toes or around mouth, & muscle twitching indicates hypocalcemia & tetany
-have IV cal gluconate or cal chloride ready
-if drain, surgeon will remove after 2 days
Client is unable to stand or walk, is dependent for all care & may exhibit dementia.
Which stage of Parkinson's? - Stage 5
Client teaching following a partial glossectomy: - -speech therapist/pathologist
-avoid mouth washes with alcohol or lemon glycerin swabs
-rinse mouth w/warm sodium bicarbonate or 0.9% sodium chloride
-report swallowing difficulty
-HOB elevated
-thicken liquids
-cleanse toothbrush after each use
-temp/permenant taste changes may happen
Client teaching for anticoagulant therapy: - -bleeding precautions
-no added meds that increase bleeding
-on it for 6-8 weeks prior to hematologic dx procedure
-must have blood levels checked often
FOR A STUDENT
A client with peptic ulcer disease has a new NG tube in place with orders for NG tube
monitoring for the nurse. What is an expected finding? - scant blood may be seen for
the first 12-24 hrs
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion.
Which of the following events should the nurse recognize as contaminating the field
(Select all that apply)
A. provider drops a sterile instrument onto the near side of the sterile field
B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field
C. procedure is delayed 1hr because the provider receives an emergency call
D. nurse turns to speak to someone who enters through the door behind the nurse
E. clients hand brushes against the outer edge of the sterile field - B, C, D
A nurse has removed a sterile pack from its outside cover and place it on a clean work
surface in preparation for an invasive procedure. Which of the following flaps should the
nurse unfold first:
A. closest to body
B. right side
C. left side
D. farthest from body - D
A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the
following objects can the nurse touch without breaking sterile technique (Select all that
apply)
A. bottle containing sterile solution
B. edge of sterile drape at the base of the field
C. inner wrapping of an item on the sterile field
D. irrigation syringe on the sterile field
E. one gloved hand with the other gloved hand - C, D, E
A pt comes to the hospital with a TB induration of 10mm what would be your following
nursing action? - obtain sputum cultures
A pt has a positive TB skin test what would your first action be? - put a mask on either
the pt or yourself
ACE inhibitors side effects: - A: angioedema
C: cough
E: elevated K+
,Acute hemolytic transfusion reaction s/s: - -chills
-fever
-low back pain
-tachycardia
-flushing
-hypotension
-chest tightening/pain
-tachypnea
-nausea
-anxiety
-hemoglobinuria
Anaphylactic transfusion reaction s/s: - -wheezing
-dyspnea
-chest tightness
-cyanosis
-hypotension
Appropriate oropharyngeal suctioning; select all: - -encourage pt to deep breath &
cough prior
-monitor O2 sats
-store catheter in clean dry place for use
-perform care 3 times a day (Q 8hrs)
Asthma & dry powder inhaler teaching: - breath in forcefully
Automated external defibrillator steps: - 1. turn it on & place pads on client
2. make sure no one is touching client
3. hit analyze
4. if shock is needed, AED will do it
AV block - AV block
Before an Endoscopy (EGD): - -NPO 6-8 hr
-remove dentures
Bilateral limb involvement occurs, making walking/balancing difficult. Which stage of
Parkinson's? - Stage 2
brady - brady
Caring for a client following a stroke of the right side with left-sided hemipalegia: - -
thicken liquids/foods
-high fowlers
-speech therapist for helping w/eating & speech
-monitor gag reflex/swallowing abilities
, -have suction equipment available
-occupational therapy
-support left arm with pillows, slings, etc
Caring for a client who has pancreatitis: - -keep NPO
-NG tube to suction gastric contents
-low fat, high protein, high carb diet
Risk factors:
-high fat diet
-excessive alcohol consumption
-age
Central venous access device care: - -remove tubing & solution bag every 24 hr
-DO NOT use line for other bolus IV solutions
-sterile dressing changes
-check cap glucose Q 4-6 hr
Client care following a thyroidectomy: - -High fowler's
-support head & neck w/pillows
-avoid neck extension
-check surgical dressing & back of neck for bleeding
-have trach supplies available
-coughing & deep breathing
-check for laryngeal damage by asking client to speak when awake from anesthesia
-admin pain meds
-tingling of toes or around mouth, & muscle twitching indicates hypocalcemia & tetany
-have IV cal gluconate or cal chloride ready
-if drain, surgeon will remove after 2 days
Client is unable to stand or walk, is dependent for all care & may exhibit dementia.
Which stage of Parkinson's? - Stage 5
Client teaching following a partial glossectomy: - -speech therapist/pathologist
-avoid mouth washes with alcohol or lemon glycerin swabs
-rinse mouth w/warm sodium bicarbonate or 0.9% sodium chloride
-report swallowing difficulty
-HOB elevated
-thicken liquids
-cleanse toothbrush after each use
-temp/permenant taste changes may happen
Client teaching for anticoagulant therapy: - -bleeding precautions
-no added meds that increase bleeding
-on it for 6-8 weeks prior to hematologic dx procedure
-must have blood levels checked often
