RN 2019 Adult Medical Surgical ATI
Proctored Exam ALL FORMS 2023
GRADED ALL 3 VERSIONS
INCLUDED
1. A nurse is caring for a client who has a severe burn injury. The nurse should recognize which
of the following client findings as an indication of hypovolemic shock?
Potassium 5.2 mEq/L
2. A nurse is teaching a client who has asthma the use of a peak flow meter. After setting the
meter to the zero baseline. What is the sequence of steps the nurse should instruct the client to
take? (Move the steps into the box on the right, placing them in the selected order of
performance use all the steps.)
"Stand upright"
"Fill your lungs with a deep breath."
"Seal your lips around the mouthpiece."
"Exhibit forcefully and quickly."
"Record the highest of three consecutive readings."
3. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
- Feet elevated
4. A nurse is planning care for a client who has a pulmonary embolism and a prescription for
enoxaparin via subcutaneous injection. Which of the following interventions should the nurse
include?
a. Assess the client’s stools for occult blood
5. a nurse is caring for a client who has sealed radiation implant. which of the following actions
should the nurse take?
limit family member visits to 30 min per day
6. a nurse providing teaching for a client who has chronic kidney disease. which of the following
client statements indicates an understanding of the teaching?
a. I will spread my protein allowances over the entire day
7. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and
has a prescription for opioid analgesia. Which of the following actions should the nurse
implement to help facilitate the client's recovery?
Provide analgesic medication prior to physical activities.
8. A the medical record of a client who is 1 day postoperative following an appendectomy.
Which of the following should the nurse report to the provider ?
Hemoglobin 10 mg/dL
9. A nurse on an acute care unit is receiving a change-of-shift report for four clients. Which of
the following clients should the nurse assess first?
A client who had an acute kidney injury and has a potassium level of 6.5 mEq/L
,10. A nurse in a long-term care facility caring for a bedridden. Which of the following findings
should alert the nurse to a complication of the client’s immobility?
- blurred vision
11. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation and asks about the purpose of maintaining an elastic bandage around the residual
limb of the extremity. Which of the following is an appropriate response by the nurse?
a. “The elastic bandage will keep you from seeing the surgical site.”
b. “The elastic bandage will prevent a postoperative wound infection.”
c. “The elastic bandage will prevent excessive edema.”***
d. “The elastic bandage will keep the sutures from loosening.”
12. A nurse is preparing to administer fresh frozen plasma to a client.
Which of the following actions should the nurse take?
a. Hold the transfusion if the client is actively bleeding
b. Transfuse the plasma over 4 hours
c. Administer the transfusion through a 25-gauge saline lock
d. Administer the plasma immediately after thawing
13. A nurse caring for a client in diabetic ketoacidosis (DKA) , Which of the following is the
priority intervention by the nurse
a. Initiate a continuous IV insulin infusion
b. Begin bicarbonate continuous IV infusion
c. Check potassium levels
d. Administer 0.9% sodium chloride
14. 1. A critical care nurse is assessing a client who has a severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes
incomprehensible sounds. Which of the following Glascow Coma Scale scores should the nurse
assign the client?
B. 5
15. 1. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the
following client statements indicates an understanding of the teaching?
c. “I will expect my stools to be loose.”**
16. A home health nurse is teaching a client how to care for a peripherally inserted central
catheter in his right arm. Which of the following statements should the nurse include in the
teaching?
“Use a 10-milliliter syringe when flushing the catheter.”
,17. A nurse in the emergency department is caring for a client who has a gunshot wound to the
abdomen. Which of the following actions should the nurse take first?
a. Administer an opioid analgesic
b. Check the color of the client’s skin.
c. Remove all of the client’s clothing.
d. Prepare the client for peritoneal lavage.
18. A nurse is assessing a client who has acute pancreatitis and has been receiving total
parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to
intervene?
a. Crackles in bilateral lower lobes
19. A nurse working in the emergency department is assessing a client admitting with atrial
fibrillation. Which of the following findings should the nurse report to the provider immediately?
a. Shortness of breath
20. A nurse is reviewing a medical record of a client who has heat exhaustion with nausea and
vomiting. Which of the following prescriptions should the nurse expect to administer?
a. 0.9% sodium chloride IV solution
21. A nurse is providing discharge teaching to a client following a modified left radical
mastectomy with breast expander. Which of the following statements by the client indicates an
understanding of the teaching?
a. “I should expect less than 25 mL of secretions per day in the drainage devices.”
22. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
MENTAL CONFUSION
23. A nurse is assessing a client who reports numbness and tingling and exhibits a positive
Trousseau’s sign. Which of the following electrolyte imbalances should the nurse suspect?
d. Hypocalcemia
24. A nurse is planning care of a client who has a
newly implanted arteriovenous graft in the right
arm. Which of the following actions should the
nurse include in the plan of care?
d. Palpate the site for a thrill.
25. A nurse is caring for a client who is receiving
continuous bladder irrigation following a
transurethral resection of the prostate. The client
, reports bladder spasms and the nurse observes
decreased urinary output. Which of the following
actions should the nurse take?
a. Flush the catheter manually with 0.9% sodium chloride. **
b. Decrease traction on the catheter.
c. Administer ibuprofen 400 mg for pain relief.
d. Remove the indwelling urinary catheter.
26. A nurse is providing discharge teaching to a client who has an impaired immune system due
to chemotherapy. Which of the following information should the nurse include in the teaching?
b. Wash your perineal area two times each day with antimicrobial soap
27. 1. A nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify which of the following statements by the client indicates an
understanding of the teaching?
a. “I use my heating pad on a low-setting to keep my feet warm.”
b. “I rest my recliner with my feet elevated for about an hour every
afternoon.”***
c. “I apply a lubricating lotion to the cracked areas on the soles of my
feet every morning.”
d. “I soak my feet in hot water before trimming my toenails.”
28. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of
the following findings should the nurse expect?
b. Proteinuria
29. 1. A nurse in the emergency department admitted a client who is having a myocardial
infarction. The client has been placed on the heart monitor. Which of the following
electrocardiogram strips is indicative of a myocardial infarction? (ST elevation)
c.
30. A nurse is performing a venipuncture on an older adult client whose veins are difficult to
locate. Which of the following actions should the nurse take?
a. Tap the skin around the insertion site
Proctored Exam ALL FORMS 2023
GRADED ALL 3 VERSIONS
INCLUDED
1. A nurse is caring for a client who has a severe burn injury. The nurse should recognize which
of the following client findings as an indication of hypovolemic shock?
Potassium 5.2 mEq/L
2. A nurse is teaching a client who has asthma the use of a peak flow meter. After setting the
meter to the zero baseline. What is the sequence of steps the nurse should instruct the client to
take? (Move the steps into the box on the right, placing them in the selected order of
performance use all the steps.)
"Stand upright"
"Fill your lungs with a deep breath."
"Seal your lips around the mouthpiece."
"Exhibit forcefully and quickly."
"Record the highest of three consecutive readings."
3. A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
- Feet elevated
4. A nurse is planning care for a client who has a pulmonary embolism and a prescription for
enoxaparin via subcutaneous injection. Which of the following interventions should the nurse
include?
a. Assess the client’s stools for occult blood
5. a nurse is caring for a client who has sealed radiation implant. which of the following actions
should the nurse take?
limit family member visits to 30 min per day
6. a nurse providing teaching for a client who has chronic kidney disease. which of the following
client statements indicates an understanding of the teaching?
a. I will spread my protein allowances over the entire day
7. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and
has a prescription for opioid analgesia. Which of the following actions should the nurse
implement to help facilitate the client's recovery?
Provide analgesic medication prior to physical activities.
8. A the medical record of a client who is 1 day postoperative following an appendectomy.
Which of the following should the nurse report to the provider ?
Hemoglobin 10 mg/dL
9. A nurse on an acute care unit is receiving a change-of-shift report for four clients. Which of
the following clients should the nurse assess first?
A client who had an acute kidney injury and has a potassium level of 6.5 mEq/L
,10. A nurse in a long-term care facility caring for a bedridden. Which of the following findings
should alert the nurse to a complication of the client’s immobility?
- blurred vision
11. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation and asks about the purpose of maintaining an elastic bandage around the residual
limb of the extremity. Which of the following is an appropriate response by the nurse?
a. “The elastic bandage will keep you from seeing the surgical site.”
b. “The elastic bandage will prevent a postoperative wound infection.”
c. “The elastic bandage will prevent excessive edema.”***
d. “The elastic bandage will keep the sutures from loosening.”
12. A nurse is preparing to administer fresh frozen plasma to a client.
Which of the following actions should the nurse take?
a. Hold the transfusion if the client is actively bleeding
b. Transfuse the plasma over 4 hours
c. Administer the transfusion through a 25-gauge saline lock
d. Administer the plasma immediately after thawing
13. A nurse caring for a client in diabetic ketoacidosis (DKA) , Which of the following is the
priority intervention by the nurse
a. Initiate a continuous IV insulin infusion
b. Begin bicarbonate continuous IV infusion
c. Check potassium levels
d. Administer 0.9% sodium chloride
14. 1. A critical care nurse is assessing a client who has a severe head injury. In response to
painful stimuli, the client does not open her eyes, displays decerebrate posturing, and makes
incomprehensible sounds. Which of the following Glascow Coma Scale scores should the nurse
assign the client?
B. 5
15. 1. A nurse is providing discharge teaching to a client who has an ileostomy. Which of the
following client statements indicates an understanding of the teaching?
c. “I will expect my stools to be loose.”**
16. A home health nurse is teaching a client how to care for a peripherally inserted central
catheter in his right arm. Which of the following statements should the nurse include in the
teaching?
“Use a 10-milliliter syringe when flushing the catheter.”
,17. A nurse in the emergency department is caring for a client who has a gunshot wound to the
abdomen. Which of the following actions should the nurse take first?
a. Administer an opioid analgesic
b. Check the color of the client’s skin.
c. Remove all of the client’s clothing.
d. Prepare the client for peritoneal lavage.
18. A nurse is assessing a client who has acute pancreatitis and has been receiving total
parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to
intervene?
a. Crackles in bilateral lower lobes
19. A nurse working in the emergency department is assessing a client admitting with atrial
fibrillation. Which of the following findings should the nurse report to the provider immediately?
a. Shortness of breath
20. A nurse is reviewing a medical record of a client who has heat exhaustion with nausea and
vomiting. Which of the following prescriptions should the nurse expect to administer?
a. 0.9% sodium chloride IV solution
21. A nurse is providing discharge teaching to a client following a modified left radical
mastectomy with breast expander. Which of the following statements by the client indicates an
understanding of the teaching?
a. “I should expect less than 25 mL of secretions per day in the drainage devices.”
22. A nurse in an emergency department is assessing a client who has cirrhosis of the liver.
Which of the following is a priority finding?
MENTAL CONFUSION
23. A nurse is assessing a client who reports numbness and tingling and exhibits a positive
Trousseau’s sign. Which of the following electrolyte imbalances should the nurse suspect?
d. Hypocalcemia
24. A nurse is planning care of a client who has a
newly implanted arteriovenous graft in the right
arm. Which of the following actions should the
nurse include in the plan of care?
d. Palpate the site for a thrill.
25. A nurse is caring for a client who is receiving
continuous bladder irrigation following a
transurethral resection of the prostate. The client
, reports bladder spasms and the nurse observes
decreased urinary output. Which of the following
actions should the nurse take?
a. Flush the catheter manually with 0.9% sodium chloride. **
b. Decrease traction on the catheter.
c. Administer ibuprofen 400 mg for pain relief.
d. Remove the indwelling urinary catheter.
26. A nurse is providing discharge teaching to a client who has an impaired immune system due
to chemotherapy. Which of the following information should the nurse include in the teaching?
b. Wash your perineal area two times each day with antimicrobial soap
27. 1. A nurse is providing instructions about foot care for a client who has peripheral arterial
disease. The nurse should identify which of the following statements by the client indicates an
understanding of the teaching?
a. “I use my heating pad on a low-setting to keep my feet warm.”
b. “I rest my recliner with my feet elevated for about an hour every
afternoon.”***
c. “I apply a lubricating lotion to the cracked areas on the soles of my
feet every morning.”
d. “I soak my feet in hot water before trimming my toenails.”
28. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of
the following findings should the nurse expect?
b. Proteinuria
29. 1. A nurse in the emergency department admitted a client who is having a myocardial
infarction. The client has been placed on the heart monitor. Which of the following
electrocardiogram strips is indicative of a myocardial infarction? (ST elevation)
c.
30. A nurse is performing a venipuncture on an older adult client whose veins are difficult to
locate. Which of the following actions should the nurse take?
a. Tap the skin around the insertion site
