ATI RN MEDICAL SURGICAL PROCTORED EXAMS 25 ATI
RN MEDICAL SURGICAL PROCTORED EXAMS 25 LATEST LATEST
MULTIPLE VERSIONS EXAMS GRADE A+MULTIPLE VERSIONS
OF THE EXAM A+ GRADED EXAM
Medical Surgical ATI
Lyme Disease
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Understanding of the patient teaching. ANS: My joints ache because I have Lyme disease.
Chronic complications memory problem and fatigue
Musculoskeletal: Osteoporosis/Osteomyelitis
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of
the following findings is a manifestation of this condition? ANS: Pain that increases with passive
movement. Other s/s diminished pulse or pulselessness and capillary refill greater than 2
seconds in the affected extremity. Warmth indicates infection.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? Flex the foot every hour when
awake. Avoid placing pillows under the knee. Elevate the leg when sitting in a chair to reduce
edema and pain. Keep the operative leg in a neutral position when resting in bed
Teaching external fixation device for fracture of lower extremity: use crutches with rubber tip.
Casts/splints/boots applied. Continuous use for 4-6 weeks. Teach wound and pin care. Only provider
can adjust.
Post-op open reduction internal fixation of the ankle. What assessment report: extremity cool
on palpation. Other findings to report: pallor, cool temp, paresthesia
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following
nonpharmacological interventions should the nurse suggest to the client to reduce pain?
Alternate application of heat and cold to the affected joints. Diet high in nutrients, such as
protein, vitamins, and iron, to promote tissue repair. Elevation of the affected extremities does
not relieve the painful inflammation caused by rheumatoid arthritis.
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Elevation of the extremities can assist with managing the pain of a client who has peripheral
vascular disease. Regular exercise is important to prevent stiffness.
Caring for a client with hx of a compound fracture, 3 wks ago.
Unexpected finding showing osteomyelitis? ANS: Sedimentation rate. An increased
sedimentation rate occurs when a client has any type of inflammatory process, such as
osteomyelitis.
A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client
which of the following medications can increase their risk of developing osteoporosis? ANS:
Prednisone. The nurse should instruct the client that prednisone can increase the risk for
developing osteoporosis due to suppression of bone formation, and an increase in bone
resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.
Conjugated estrogen reduces risk. Colchicine can cause aplastic anemia.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following
instructions should the nurse include? Walk for 30 mins four times per week. Other teaching:
Glucosamine for pain, avoid exercises that cause jarring motions, such as jogging, take over-the-
counter calcium supplements.
Procedures
Suctioning client tracheostomy tube. Signs of hypoxia: The client’s heart rate increases.
Coughing is expected. Late signs are diaphoresis and a decrease in blood pressure and will not
be seen now. An increase in blood pressure is an early sign.
A nurse is caring for a client who has an arterial line. Nursing action to take? ANS: Place a
pressure bag around the flush solution. Arterial line used for ABG samples and hemodynamic
monitoring. Supine, HOB 60 degrees.
A nurse is assessing a client following the completion of hemodialysis. Which of the following
findings is the nurse's priority to report to the provider? Restlessness. Expected: inc temp, dec
BP, weight loss.
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide? Hemodialysis
is sometimes required following surgery. Transplant can come from a living or deceased donor.
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Lifelong immunosuppressive therapy is necessary for the organ recipient. Following transplant,
clients should follow dietary restrictions to prevent rejection.
A nurse is caring for a client who had a nephrostomy tube inserted 12hrs ago. Report to the
doc? ANS: The client complains of back pain. This indicates the tube may have clogged or is
dislodged. Report decrease in UO. Red tinged urine expected post 12-24hrs
Planning care for a client who is scheduled for a thoracentesis. Nursing interventions. ANS:
Encourage the client to take deep breaths after the procedure. Other: upright position, arm resting
overhead table, local anesthetic, npo not needed. Resumes activity within 1 hr post procedure.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The
client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following
vital sign changes should alert the nurse that the client might be hemorrhaging? HR 110. one of
the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which
occurs to compensate for blood loss. An early sign of hemorrhage is a slight increase in the
diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An
increase in blood pressure postoperatively can indicate that the client is in pain. An increase in
the respiratory rate from the client’s baseline is an indication of hemorrhage. An increase in
temperature from the client’s baseline is an indication of infection, not hemorrhage.
A nurse is caring for a client following extubation of an endotracheal tube 10 mins ago. Priority
to report? ANS: Stridor. Expected findings: hoarseness, sore throat, oral secretions
TURP post opp, clots in indwelling catheter: irrigate the catheter. Traction applied to reduce risk
of bleeding.
A nurse is planning for a client who is postoperative following a laparotomy and has a closed-
suction drain. Which of the following actions should the nurse take to manage the drain? ANS:
Compress the drain reservoir after emptying
Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the
drain, and into the reservoir. A closed-suction drain uses a reservoir for collecting drainage and
applies negative pressure, which allows the drainage to collect in the reservoir rather than
relying on gravity, and does not require wall suction. A Penrose drain allows drainage to collect
on a sterile gauze dressing.
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A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS)
for the management of bone cancer pain. The nurse should explain that applying a TENS unit to
the painful area has which of the following effects? A tingling sensation replacing the pain. A
TENS unit applies small electric currents to the painful area, with the client increasing the
current until the “pins and needles” sensation overrides the pain.
Elimination
8 hr post opp total hip arthroplasty. Unable to void in a bedpan. Action take first: Scan the
bladder with a portable ultrasound.
TB
Discharge teaching active TB (Tuberculosis): Sputum specimens q 2-4 w until there are three
negative cultures. Client no longer contagious post 2-3 weeks of initiation of TB medications.
Family members take no precautions because they have already been exposed. Follow up
evaluation chest X-Ray, not skin
test.
TB patient and family education: Family members in the household should undergo TB testing.
Other teaching: cover mouth when cough/sneeze and suppose tissues in plastic bag. Wear
mask in public.
TB precautions: Airborne. Other diseases that need airborne: measles, varicella, disseminated
varicella zoster. Droplet: flu, rubella, pneumonia, streptococcal pharyngitis, pertussis, mumps.
Contact: MRSA, VRE, respiratory syncytial virus, scabies, c-diff. Protective:
immunocompromised.
Medications
Inc ICP. Receive Mannitol. Adverse Effect: Other adverse effects: tachycardia, edema, dyspnea,
decreased O2 sat. Therapeutic effect: increased urinary output.
Teaching for psyllium (bulk forming laxative). 240 ml or 8 oz of water drink post administration.
Works in 12-24 hrs, expect BM regularity in 2-3 days. Take it post meals. Increase dietary fiber to
help constipation.
Warfarin for Afib, desired outcome: INR 2.5 (2-3 target range). Heparin aPTT 45-90
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RN MEDICAL SURGICAL PROCTORED EXAMS 25 LATEST LATEST
MULTIPLE VERSIONS EXAMS GRADE A+MULTIPLE VERSIONS
OF THE EXAM A+ GRADED EXAM
Medical Surgical ATI
Lyme Disease
A nurse is providing teaching to a client who has a severe form of stage II Lyme disease.
Understanding of the patient teaching. ANS: My joints ache because I have Lyme disease.
Chronic complications memory problem and fatigue
Musculoskeletal: Osteoporosis/Osteomyelitis
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of
the following findings is a manifestation of this condition? ANS: Pain that increases with passive
movement. Other s/s diminished pulse or pulselessness and capillary refill greater than 2
seconds in the affected extremity. Warmth indicates infection.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? Flex the foot every hour when
awake. Avoid placing pillows under the knee. Elevate the leg when sitting in a chair to reduce
edema and pain. Keep the operative leg in a neutral position when resting in bed
Teaching external fixation device for fracture of lower extremity: use crutches with rubber tip.
Casts/splints/boots applied. Continuous use for 4-6 weeks. Teach wound and pin care. Only provider
can adjust.
Post-op open reduction internal fixation of the ankle. What assessment report: extremity cool
on palpation. Other findings to report: pallor, cool temp, paresthesia
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following
nonpharmacological interventions should the nurse suggest to the client to reduce pain?
Alternate application of heat and cold to the affected joints. Diet high in nutrients, such as
protein, vitamins, and iron, to promote tissue repair. Elevation of the affected extremities does
not relieve the painful inflammation caused by rheumatoid arthritis.
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Distribution of this document is illegal
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Elevation of the extremities can assist with managing the pain of a client who has peripheral
vascular disease. Regular exercise is important to prevent stiffness.
Caring for a client with hx of a compound fracture, 3 wks ago.
Unexpected finding showing osteomyelitis? ANS: Sedimentation rate. An increased
sedimentation rate occurs when a client has any type of inflammatory process, such as
osteomyelitis.
A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client
which of the following medications can increase their risk of developing osteoporosis? ANS:
Prednisone. The nurse should instruct the client that prednisone can increase the risk for
developing osteoporosis due to suppression of bone formation, and an increase in bone
resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.
Conjugated estrogen reduces risk. Colchicine can cause aplastic anemia.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following
instructions should the nurse include? Walk for 30 mins four times per week. Other teaching:
Glucosamine for pain, avoid exercises that cause jarring motions, such as jogging, take over-the-
counter calcium supplements.
Procedures
Suctioning client tracheostomy tube. Signs of hypoxia: The client’s heart rate increases.
Coughing is expected. Late signs are diaphoresis and a decrease in blood pressure and will not
be seen now. An increase in blood pressure is an early sign.
A nurse is caring for a client who has an arterial line. Nursing action to take? ANS: Place a
pressure bag around the flush solution. Arterial line used for ABG samples and hemodynamic
monitoring. Supine, HOB 60 degrees.
A nurse is assessing a client following the completion of hemodialysis. Which of the following
findings is the nurse's priority to report to the provider? Restlessness. Expected: inc temp, dec
BP, weight loss.
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a
kidney transplant. Which of the following information should the nurse provide? Hemodialysis
is sometimes required following surgery. Transplant can come from a living or deceased donor.
Downloaded by: NURSEDENIM |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Lifelong immunosuppressive therapy is necessary for the organ recipient. Following transplant,
clients should follow dietary restrictions to prevent rejection.
A nurse is caring for a client who had a nephrostomy tube inserted 12hrs ago. Report to the
doc? ANS: The client complains of back pain. This indicates the tube may have clogged or is
dislodged. Report decrease in UO. Red tinged urine expected post 12-24hrs
Planning care for a client who is scheduled for a thoracentesis. Nursing interventions. ANS:
Encourage the client to take deep breaths after the procedure. Other: upright position, arm resting
overhead table, local anesthetic, npo not needed. Resumes activity within 1 hr post procedure.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The
client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following
vital sign changes should alert the nurse that the client might be hemorrhaging? HR 110. one of
the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which
occurs to compensate for blood loss. An early sign of hemorrhage is a slight increase in the
diastolic blood pressure. As bleeding progresses, the systolic blood pressure will decrease. An
increase in blood pressure postoperatively can indicate that the client is in pain. An increase in
the respiratory rate from the client’s baseline is an indication of hemorrhage. An increase in
temperature from the client’s baseline is an indication of infection, not hemorrhage.
A nurse is caring for a client following extubation of an endotracheal tube 10 mins ago. Priority
to report? ANS: Stridor. Expected findings: hoarseness, sore throat, oral secretions
TURP post opp, clots in indwelling catheter: irrigate the catheter. Traction applied to reduce risk
of bleeding.
A nurse is planning for a client who is postoperative following a laparotomy and has a closed-
suction drain. Which of the following actions should the nurse take to manage the drain? ANS:
Compress the drain reservoir after emptying
Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the
drain, and into the reservoir. A closed-suction drain uses a reservoir for collecting drainage and
applies negative pressure, which allows the drainage to collect in the reservoir rather than
relying on gravity, and does not require wall suction. A Penrose drain allows drainage to collect
on a sterile gauze dressing.
Downloaded by: NURSEDENIM |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS)
for the management of bone cancer pain. The nurse should explain that applying a TENS unit to
the painful area has which of the following effects? A tingling sensation replacing the pain. A
TENS unit applies small electric currents to the painful area, with the client increasing the
current until the “pins and needles” sensation overrides the pain.
Elimination
8 hr post opp total hip arthroplasty. Unable to void in a bedpan. Action take first: Scan the
bladder with a portable ultrasound.
TB
Discharge teaching active TB (Tuberculosis): Sputum specimens q 2-4 w until there are three
negative cultures. Client no longer contagious post 2-3 weeks of initiation of TB medications.
Family members take no precautions because they have already been exposed. Follow up
evaluation chest X-Ray, not skin
test.
TB patient and family education: Family members in the household should undergo TB testing.
Other teaching: cover mouth when cough/sneeze and suppose tissues in plastic bag. Wear
mask in public.
TB precautions: Airborne. Other diseases that need airborne: measles, varicella, disseminated
varicella zoster. Droplet: flu, rubella, pneumonia, streptococcal pharyngitis, pertussis, mumps.
Contact: MRSA, VRE, respiratory syncytial virus, scabies, c-diff. Protective:
immunocompromised.
Medications
Inc ICP. Receive Mannitol. Adverse Effect: Other adverse effects: tachycardia, edema, dyspnea,
decreased O2 sat. Therapeutic effect: increased urinary output.
Teaching for psyllium (bulk forming laxative). 240 ml or 8 oz of water drink post administration.
Works in 12-24 hrs, expect BM regularity in 2-3 days. Take it post meals. Increase dietary fiber to
help constipation.
Warfarin for Afib, desired outcome: INR 2.5 (2-3 target range). Heparin aPTT 45-90
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