med surg ATI proctored exam (Answered
2022/2023)
A nurse in an emergency department is preparing to perform an ocular irrigation
for a client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation
d. Perform the irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer's via continuous IV infusion at
200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min
should the nurse set the IV pump to administer? Round to near whole number
33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription
for sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention
b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left
total hip arthroplasty. Which of the following instructions should the nurse
include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom
d. Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of
the following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 l per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hour
c. Maintain the client's affected extremity in extension
A nurse is caring for a client who has a lower extremity fracture and a
prescription for crutches. Which of the following client statements indicates that
the client is adapting to their role change?
a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
,d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore
a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
A nurse is caring for a client who has gastroenteritis. Which of the following
assessment findings should the nurse recognize as an indication that the client is
experiencing dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP
d. Decreased BP
A nurse is caring for a client who has a contusion of the brainstem and reports
thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse
should anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside
a. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started
therapy with an ACE inhibitor and reports a nagging dry cough. Which of the
following responses by the nurse is appropriate?
a. "your cough may require that you stop or change your medication"
b. "Increasing your daily fluid intake may eliminate your cough"
c. "sucking on lozenge may reduce the frequency of your cough"
d. You cough should go away in time"
a. "your cough may require that you stop or change your medication"
A nurse is taking an admission history from a client who reports Raynaud's
disease. Which of the following assessment findings should the nurse identify as
a potential trigger for exacerbations
of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch
d. Using a nicotine transdermal patch
A nurse is caring for a client who has a central venous access device and notes
the tubing has become disconnected. The client develops dyspnea and
tachycardia. Which of the following
actions should the nurse take first?
a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter
d. Clamp the catheter
, A nurse is completing an assessment of an older adult client and notes reddened
areas over the bony prominences, but the client's skin is intact. Which of the
following interventions should the nurse include in the plan of care?
a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day
c. Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple
sclerosis. Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society
a. Discuss recommendations for eating and swallowing techniques
A nurse in the emergency department is assessing a client. Which of the
following actions should the nurse take first? Exhibit
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray
c. Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify risk factors for
colorectal cancer. The nurse should identify which of the following findings as
increasing the client's risk?
a. History of Crohn's disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
a. History of Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells
the nurse, "I'm not sure I want to have a mastectomy." Which of the following
statements should the nurse make?
a. "I can give you a list of other people who had the same procedure"
b. "You will be cancer-free if you have the procedure"
c. "I can give you additional information about the procedure"
d. "You should should get a second opinion regarding the procedure"
c. "I can give you additional information about the procedure"
A nurse is preparing to administer a unit of packed RBCs to a client who is
anemic. Identify the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank
2022/2023)
A nurse in an emergency department is preparing to perform an ocular irrigation
for a client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation
d. Perform the irrigation with sterile water for irrigation
A nurse is preparing to administer lactated ringer's via continuous IV infusion at
200 ml/hr. The IV tubing has a drop factor of 10 drops/ml. How many gtt/min
should the nurse set the IV pump to administer? Round to near whole number
33 gtt/min
A nurse is providing discharge teaching to a client who has a new prescription
for sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
a. I can keep my medications for 1 year before replacing it
b. I should lie down when I take this medication
c. I should discontinue this medication if I develop a headache
d. I can take up to five tablets in 15 minutes before seeking medical attention
b. I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following a left
total hip arthroplasty. Which of the following instructions should the nurse
include in the teaching?
a. Clean the incision daily with hydrogen peroxide
b. You can cross your legs the ankles when sitting down
c. You should use an incentive spirometer every 8 hours
d. Install a raised toilet seat in your bathroom
d. Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of
the following actions should the nurse take?
a. Keep the client on bed rest for 24 hours
b. Limit the client's fluid intake to 1 l per day
c. Maintain the client's affected extremity in extension
d. Change the client's dressing every 8 hour
c. Maintain the client's affected extremity in extension
A nurse is caring for a client who has a lower extremity fracture and a
prescription for crutches. Which of the following client statements indicates that
the client is adapting to their role change?
a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
b. These crutches will make it impossible to care for my child
c. I feel bad that I have to ask my partner to keep the house clean
,d. Its going to be difficult to tell my parents I cant take them to their appointments
anymore
a. I will need to have my partner take over shopping for groceries and cooking the
meals for us
A nurse is caring for a client who has gastroenteritis. Which of the following
assessment findings should the nurse recognize as an indication that the client is
experiencing dehydration?
a. Pitting, dependent edema
b. Distended jugular veins
c. Increased BP
d. Decreased BP
d. Decreased BP
A nurse is caring for a client who has a contusion of the brainstem and reports
thirst. The client's urinary output was 4,000 ml over the past 24 hour. The nurse
should anticipate a prescription for which of the following IV medication?
a. Desmopressin
b. Epinephrine
c. Furosemide
d. Nitroprusside
a. Desmopressin
A nurse in a clinic receives a phone call from a client who recently started
therapy with an ACE inhibitor and reports a nagging dry cough. Which of the
following responses by the nurse is appropriate?
a. "your cough may require that you stop or change your medication"
b. "Increasing your daily fluid intake may eliminate your cough"
c. "sucking on lozenge may reduce the frequency of your cough"
d. You cough should go away in time"
a. "your cough may require that you stop or change your medication"
A nurse is taking an admission history from a client who reports Raynaud's
disease. Which of the following assessment findings should the nurse identify as
a potential trigger for exacerbations
of Raynaud's?
a. Eating a strict vegetarian diet
b. A history of herpes zoster
c. Taking amiodipine for hypertension
d. Using a nicotine transdermal patch
d. Using a nicotine transdermal patch
A nurse is caring for a client who has a central venous access device and notes
the tubing has become disconnected. The client develops dyspnea and
tachycardia. Which of the following
actions should the nurse take first?
a. Perform an ECG
b. Obtain ABG values
c. Turn the client to his left side
d. Clamp the catheter
d. Clamp the catheter
, A nurse is completing an assessment of an older adult client and notes reddened
areas over the bony prominences, but the client's skin is intact. Which of the
following interventions should the nurse include in the plan of care?
a. Turn and reposition the client every 4 hr
b. Apply an occlusive dressing
c. Support bony prominences with pillows
d. Massage the reddened areas three times a day
c. Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple
sclerosis. Which of the following actions is the priority for the nurse to take?
a. Discuss recommendations for eating and swallowing techniques
b. List strategies for family coping when dealing with possible role changes
c. Review the use of adaptive grooming devices to promote client independence
d. Give the client information about the local national multiple sclerosis society
a. Discuss recommendations for eating and swallowing techniques
A nurse in the emergency department is assessing a client. Which of the
following actions should the nurse take first? Exhibit
a. Obtain a sputum sample for culture
b. Administer ondansetron
c. Initiate airborne precautions
d. Prepare the client for a chest x-ray
c. Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify risk factors for
colorectal cancer. The nurse should identify which of the following findings as
increasing the client's risk?
a. History of Crohn's disease
b. BMI of 24
c. Diet high in fiber
d. Age 46 years
a. History of Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells
the nurse, "I'm not sure I want to have a mastectomy." Which of the following
statements should the nurse make?
a. "I can give you a list of other people who had the same procedure"
b. "You will be cancer-free if you have the procedure"
c. "I can give you additional information about the procedure"
d. "You should should get a second opinion regarding the procedure"
c. "I can give you additional information about the procedure"
A nurse is preparing to administer a unit of packed RBCs to a client who is
anemic. Identify the sequence of steps the nurse should follow.
e. Remain with the client for the first 15 to 30 min of the infusion
a. Obtain venous access using 19-gauge needle
c. Verify blood compatibility with another nurse
d. Initiate transfusion of the unit of packed RBCs
b. Obtain the unit of packed RBCs from blood bank
