Med Surg ATI Book Questions And Answers
(All Correct Verified Answers)
A nurse is caring for an older adult client who has a new diagnosis of type 2
diabetes and reports difficulty following the diet and remembering to take the
prescribed medication. Which of the following actions should the nurse take to
promote client compliance? (Select all that apply.)
a. Ask the dietitian to assist with meal planning
b. Contact the client's support system
c. Assess for age-related cognitive awareness
d. Encourage the use of a daily medication dispenser
e. Provide educational materials for home use
A., B., D., E.
A nurse in a health care clinic is evaluating the level of wellness for clients using
the illness-wellness continuum tool. The nurse should identify which of the
following clients as being at the center of the continuum?
a. A college student who has influenza
b. An older adult who has a new diagnosis of type 2 diabetes
c. A new mother who has a UTI
d. A young male client who has a long history of well-controlled rheumatoid
arthritis
D.
A nurse is evaluating clients at a health fair for modifiable variables affecting
health and wellness. The nurse should identify which of the following variables as
modifiable? (Select all that apply.)
a. Smoking on social occasions
b. BMI of 28
c. Alopecia
d. Trisomy 21
e. History of reflux
A., B., E.
A nurse is caring for a client who was just told she has breast cancer. The nurse
evaluates the client's response. Which of the following statements by the client
reflects a lack of understanding of an illness perspective?
a. "I have no family history of breast cancer."
b. "I need a second opinion. There is no lump."
c. "I am glad we live in the city near several large hospitals."
d. "I will schedule surgery next week, over the holidays."
B.
,A nurse on a med-surg unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
a. Client who has an ulceration of the right heel whose BG is 300 mg/dL
b. Client who reports right calf pain and SOB
c. Client who has blood on a pressure dressing in a femoral area following a
cardiac catheterization
d. Client who has dark red coloration of left toes and absent pedal pulse
B.
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply.)
a. Induce vomiting
b. Instill activated charcoal
c. Perform a gastric lavage with aspiration
d. Administer syrup of ipecac
e. Infuse IV fluids
B., C., E.
A nurse in the ED is caring for a client who fell through the ice on a pond and is
unresponsive and breathing slowly. Which of the following actions should the
nurse take? (Select all that apply.)
a. Remove wet clothing
b. Maintain normal room temp
c. Apply warm blankets
d. Apply a heat lamp
e. Infuse warmed IV fluids
A., C., D., E.
A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of
the following techniques should the nurse use to open the client's airway?
a. Head-tilt, chin-lift
b. Modified jaw thrust
c. Hyperextension of the head
d. Flexion of the head
A.
A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
a. Perform defibrillation
b. Prepare for transcutaneous pacing
c. Administer IV epinephrine
d. Elevate the client's lower extremities
C.
,A nurse is caring for a client who is post procedure following lumbar puncture
and reports a throbbing headache when sitting upright. Which of the following
actions should the nurse take? (Select all that apply.)
a. Use the Glasgow Coma Scale when assessing the client
b. Assist the client to a supine position
c. Administer an opioid medication
d. Encourage the client to increase fluid intake
e. Instruct the client to perform deep breathing and coughing exercises
B., C., D.
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter for ICP monitoring. The nurse should monitor the client
for which of the following complications related to the ventriculostomy?
a. Headache
b. Infection
c. Aphasia
d. Hypertension
B.
A nurse is assessing a client for changes in the level of consciousness using the
GCS. The client opens his eyes when spoken to, speaks incoherently, and moves
his extremities when pain is applied. Which of the following GCS scores should
the nurse document?
a. E2 + V3 + M5 = 10
b. E3 + V4 + M4 = 11
c. E4 + V5 + M6 = 15
d. E2 + V2 + M4 = 8
B.
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply.)
a. "I think I might be pregnant."
b. "I take warfarin."
c. "I take antihypertensive medication."
d. "I am allergic to shrimp."
e. "I ate a light breakfast this morning."
A., B., D., E.
A nurse is providing education to a client who is to undergo an EEG the next day.
Which of the following information should the nurse include in the teaching?
a. "Do not wash your hair the morning of the procedure."
b. "Try to stay awake most of the night prior to the procedure."
c. "The procedure will take approximately 15 minutes."
d. "You will need to lie flat for 4 hours after the procedure."
, B.
A nurse is assessing the pain level of a client who came to the ED reporting
severe abdominal pain. The nurse asks the client whether he has nausea and has
been vomiting. The nurse is assessing which of the following components of a
pain assessment?
a. Presence of associated manifestations
b. Location of the pain
c. Pain quality
d. Aggravating and relieving factors
A.
A nurse is assessing a client who is reporting pain despite analgesia. Which of
the following actions should the nurse take to assess the intensity of the client's
pain?
a. Ask the client what precipitates his pain
b. Question the client about the location of his pain
c. Offer the client a pain scale to measure his pain
d. Use open-ended questions to identify the sensation of his pain
C.
A nurse is caring for a client who is receiving morphine via a PCA infusion device
after abdominal surgery. Which of the following client statements indicates that
the client understands how to use the device?
a. "I'll wait to use the device until it's absolutely necessary."
b. "I'll be careful about pushing the button so I don't get an overdose."
c. "I should tell the nurse is the pain doesn't stop after I use this device."
d. "I will ask my son to push the dose button when I am sleeping."
C.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the
following information should the nurse include?
a. Most clients exaggerate their level of pain
b. Pain must have an identifiable source to justify the use of opioids
c. Objective data are essential in assessing pain
d. Pain is whatever the client says it is
D.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the
following findings should the nurse identify as adverse effects of opioid
analgesics? (Select all that apply.)
a. Urinary incontinence
b. Diarrhea
c. Bradypnea
d. Orthostatic hypotension
e. Nausea
(All Correct Verified Answers)
A nurse is caring for an older adult client who has a new diagnosis of type 2
diabetes and reports difficulty following the diet and remembering to take the
prescribed medication. Which of the following actions should the nurse take to
promote client compliance? (Select all that apply.)
a. Ask the dietitian to assist with meal planning
b. Contact the client's support system
c. Assess for age-related cognitive awareness
d. Encourage the use of a daily medication dispenser
e. Provide educational materials for home use
A., B., D., E.
A nurse in a health care clinic is evaluating the level of wellness for clients using
the illness-wellness continuum tool. The nurse should identify which of the
following clients as being at the center of the continuum?
a. A college student who has influenza
b. An older adult who has a new diagnosis of type 2 diabetes
c. A new mother who has a UTI
d. A young male client who has a long history of well-controlled rheumatoid
arthritis
D.
A nurse is evaluating clients at a health fair for modifiable variables affecting
health and wellness. The nurse should identify which of the following variables as
modifiable? (Select all that apply.)
a. Smoking on social occasions
b. BMI of 28
c. Alopecia
d. Trisomy 21
e. History of reflux
A., B., E.
A nurse is caring for a client who was just told she has breast cancer. The nurse
evaluates the client's response. Which of the following statements by the client
reflects a lack of understanding of an illness perspective?
a. "I have no family history of breast cancer."
b. "I need a second opinion. There is no lump."
c. "I am glad we live in the city near several large hospitals."
d. "I will schedule surgery next week, over the holidays."
B.
,A nurse on a med-surg unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
a. Client who has an ulceration of the right heel whose BG is 300 mg/dL
b. Client who reports right calf pain and SOB
c. Client who has blood on a pressure dressing in a femoral area following a
cardiac catheterization
d. Client who has dark red coloration of left toes and absent pedal pulse
B.
A nurse is caring for a client who has ingested a toxic agent. Which of the
following actions should the nurse plan to take? (Select all that apply.)
a. Induce vomiting
b. Instill activated charcoal
c. Perform a gastric lavage with aspiration
d. Administer syrup of ipecac
e. Infuse IV fluids
B., C., E.
A nurse in the ED is caring for a client who fell through the ice on a pond and is
unresponsive and breathing slowly. Which of the following actions should the
nurse take? (Select all that apply.)
a. Remove wet clothing
b. Maintain normal room temp
c. Apply warm blankets
d. Apply a heat lamp
e. Infuse warmed IV fluids
A., C., D., E.
A nurse in the ED is assessing a client who is unresponsive. The client's partner
states, "He was pulling weeds in the yard and slumped to the ground." Which of
the following techniques should the nurse use to open the client's airway?
a. Head-tilt, chin-lift
b. Modified jaw thrust
c. Hyperextension of the head
d. Flexion of the head
A.
A nurse is reviewing the common emergency management protocol for clients
who have asystole. Which of the following actions should the nurse plan to take
during this cardiac emergency?
a. Perform defibrillation
b. Prepare for transcutaneous pacing
c. Administer IV epinephrine
d. Elevate the client's lower extremities
C.
,A nurse is caring for a client who is post procedure following lumbar puncture
and reports a throbbing headache when sitting upright. Which of the following
actions should the nurse take? (Select all that apply.)
a. Use the Glasgow Coma Scale when assessing the client
b. Assist the client to a supine position
c. Administer an opioid medication
d. Encourage the client to increase fluid intake
e. Instruct the client to perform deep breathing and coughing exercises
B., C., D.
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter for ICP monitoring. The nurse should monitor the client
for which of the following complications related to the ventriculostomy?
a. Headache
b. Infection
c. Aphasia
d. Hypertension
B.
A nurse is assessing a client for changes in the level of consciousness using the
GCS. The client opens his eyes when spoken to, speaks incoherently, and moves
his extremities when pain is applied. Which of the following GCS scores should
the nurse document?
a. E2 + V3 + M5 = 10
b. E3 + V4 + M4 = 11
c. E4 + V5 + M6 = 15
d. E2 + V2 + M4 = 8
B.
A nurse is developing a plan of care for a client who is scheduled for cerebral
angiography with contrast dye. Which of the following statements by the client
should the nurse report to the provider? (Select all that apply.)
a. "I think I might be pregnant."
b. "I take warfarin."
c. "I take antihypertensive medication."
d. "I am allergic to shrimp."
e. "I ate a light breakfast this morning."
A., B., D., E.
A nurse is providing education to a client who is to undergo an EEG the next day.
Which of the following information should the nurse include in the teaching?
a. "Do not wash your hair the morning of the procedure."
b. "Try to stay awake most of the night prior to the procedure."
c. "The procedure will take approximately 15 minutes."
d. "You will need to lie flat for 4 hours after the procedure."
, B.
A nurse is assessing the pain level of a client who came to the ED reporting
severe abdominal pain. The nurse asks the client whether he has nausea and has
been vomiting. The nurse is assessing which of the following components of a
pain assessment?
a. Presence of associated manifestations
b. Location of the pain
c. Pain quality
d. Aggravating and relieving factors
A.
A nurse is assessing a client who is reporting pain despite analgesia. Which of
the following actions should the nurse take to assess the intensity of the client's
pain?
a. Ask the client what precipitates his pain
b. Question the client about the location of his pain
c. Offer the client a pain scale to measure his pain
d. Use open-ended questions to identify the sensation of his pain
C.
A nurse is caring for a client who is receiving morphine via a PCA infusion device
after abdominal surgery. Which of the following client statements indicates that
the client understands how to use the device?
a. "I'll wait to use the device until it's absolutely necessary."
b. "I'll be careful about pushing the button so I don't get an overdose."
c. "I should tell the nurse is the pain doesn't stop after I use this device."
d. "I will ask my son to push the dose button when I am sleeping."
C.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the
following information should the nurse include?
a. Most clients exaggerate their level of pain
b. Pain must have an identifiable source to justify the use of opioids
c. Objective data are essential in assessing pain
d. Pain is whatever the client says it is
D.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the
following findings should the nurse identify as adverse effects of opioid
analgesics? (Select all that apply.)
a. Urinary incontinence
b. Diarrhea
c. Bradypnea
d. Orthostatic hypotension
e. Nausea
