ATI RN MED SURG PROCTORED EXAM 2020 ACTUAL EXAM QUESTIONS
WITH DETAILED VERIFIED SOLUTIONS WITH RATIONALES/NEW/A+ GRADE
ASSURED
• A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure
alarm sounds. Which of the following situations should the nurse recognize as a cause of the
alarm?
• Excess secretions: high pressure alarm
• Kinks in the tubing: causes obstruction-high pressure alarm
• Artificial airway cuff leak (correct): Interferes with oxygenation and causes the
low- pressure alarm to sound
• Biting on the endotracheal tube: causes high pressure alarm to sound
• A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which
of the following statements by the client indicates an understanding of the teaching?
• “I should dip a cotton-tip applicator into full-strength hydrogen peroxide to cleanse
around my stoma.”: Use gauze squares moistened in 0.9% NaCl to cleanse around
the stoma or, if prescribes half-strength hydrogen-peroxide can be used on the skin
to clean crusty ares. Using a cotton-tipped applicator places the client at risk for
aspiration of cotton fibers. Also, the client should be careful not get hydrogen
peroxide into the tracheal stoma.
• “I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to
absorb drainage.”: cutting a 4-inch square gauze dressing places the client at risk
aspiration of gauze fibers. The client should apply a commercially-prepared split
gauze tracheostomy dressing under the flange of the tracheostomy tube
• “I should remove the old twill ties after new ties are in place.” (correct): As a
safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. The practice can prevent accidental decannulation
• “I should apply suction while inserting the catheter into my tracheostomy tube.”:
apply suction only when withdrawing to prevent tissue trauma.
• A nurse is caring for four clients. Which of the following clients is at greatest risk for
pulmonary embolism?
• A client who is 48 hours post-op following a total hip arthroplasty (correct): identify
that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a
pulmonary embolus because of decreased mobility of the affected extremity and an
increased amount of blood clots forming in the veins of the thigh following hip surgery.
Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The
nurse should intervene to reduce the risk by applying sequential compression devices or
anti-embolic stockings and by administering anticoagulant medications.
• A client who is 8 hours post-op following an open surgical appendectomy: is at a
low risk for developing a pulmonary embolism. The greatest risk to this client is
, peritonitis. There is another client who is at greater risk for developing a
pulmonary embolism.
• A client who is 2hr post-op following an open reduction external fixation of the
right radius: low risk for pulmonary embolism. The greatest risk to this client is
neurovascular compromise. There is another client who is at greater risk for
developing a pulmonary embolism.
• A client who is 4hr post-op following a laparoscopic cholecystectomy: low risk for
pulmonary embolism. Some clients develop pain from carbon dioxide retention in the
abdomen following a laparoscopic cholecystectomy. There is another client who is at
greater risk for developing a pulmonary embolism.
• A nurse is caring for a newly admitted client who has emphysema. The nurse should place
the client in which of the following positions to promote effective breathing?
• Lateral position with a pillow at the back and over the chest to support the arm:
promotes alignment of the back and can be good position for sleeping. However,
this position does not promote maximum chest expansion to facilitate breathing
• High-Fowler’s position with the arms supported on the overbed table (Correct) –
allows greater expansion of the chest, such as sitting up right and leaning slightly
forward while supporting both arms with pillows for comfort on the overbed table
• Semi-Fowler’s position with pillows supporting both arms: Has the head and
truck elevated to a 30-45 degree angle, does not promote maximum chest
expansion to facilitate breathing
• Supine position with the head of the ed elevated to 15 degrees: allows the
diaphragm and abdominal organs to place pressure on the thoracic cavity and
compromise chest expansion. This position does not promote maximum chest
expansion to facilitate breathing.
• A nurse is caring for a client who had asthma and is receiving albuterol. For which of the
following adverse effects should the nurse monitor the client?
• Hyperkalemia: monitor; potential adverse effect
• Dyspnea: monitor for a decrease in dyspnea; decrease is a therapeutic effect, not
an adverse
• Tachycardia (Correct) – monitor; common adverse effect of this medication,
especially if the client uses albuterol on a regular basis
• Candidiasis: monitor who is taking an inhaled glucocorticoid, such as
beclomethasone, for candidiasis
• A nurse is preparing a client for discharge following a bronchoscopy with the use of
moderate sedation. The nurse should identify that which of the following assessments is
the priority?
• Presence of gag reflex (Correct) – greatest risk (aspiration) due to depressed gag reflex.
Therefore, the priority assessment by the nurse is to determine the return of the gag
reflex
• Pain level rating using a 0-10 scale: risk for increased pain because of the introduction
of the scope into the trachea. However, another assessment is the priority
WITH DETAILED VERIFIED SOLUTIONS WITH RATIONALES/NEW/A+ GRADE
ASSURED
• A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure
alarm sounds. Which of the following situations should the nurse recognize as a cause of the
alarm?
• Excess secretions: high pressure alarm
• Kinks in the tubing: causes obstruction-high pressure alarm
• Artificial airway cuff leak (correct): Interferes with oxygenation and causes the
low- pressure alarm to sound
• Biting on the endotracheal tube: causes high pressure alarm to sound
• A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which
of the following statements by the client indicates an understanding of the teaching?
• “I should dip a cotton-tip applicator into full-strength hydrogen peroxide to cleanse
around my stoma.”: Use gauze squares moistened in 0.9% NaCl to cleanse around
the stoma or, if prescribes half-strength hydrogen-peroxide can be used on the skin
to clean crusty ares. Using a cotton-tipped applicator places the client at risk for
aspiration of cotton fibers. Also, the client should be careful not get hydrogen
peroxide into the tracheal stoma.
• “I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to
absorb drainage.”: cutting a 4-inch square gauze dressing places the client at risk
aspiration of gauze fibers. The client should apply a commercially-prepared split
gauze tracheostomy dressing under the flange of the tracheostomy tube
• “I should remove the old twill ties after new ties are in place.” (correct): As a
safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. The practice can prevent accidental decannulation
• “I should apply suction while inserting the catheter into my tracheostomy tube.”:
apply suction only when withdrawing to prevent tissue trauma.
• A nurse is caring for four clients. Which of the following clients is at greatest risk for
pulmonary embolism?
• A client who is 48 hours post-op following a total hip arthroplasty (correct): identify
that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a
pulmonary embolus because of decreased mobility of the affected extremity and an
increased amount of blood clots forming in the veins of the thigh following hip surgery.
Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The
nurse should intervene to reduce the risk by applying sequential compression devices or
anti-embolic stockings and by administering anticoagulant medications.
• A client who is 8 hours post-op following an open surgical appendectomy: is at a
low risk for developing a pulmonary embolism. The greatest risk to this client is
, peritonitis. There is another client who is at greater risk for developing a
pulmonary embolism.
• A client who is 2hr post-op following an open reduction external fixation of the
right radius: low risk for pulmonary embolism. The greatest risk to this client is
neurovascular compromise. There is another client who is at greater risk for
developing a pulmonary embolism.
• A client who is 4hr post-op following a laparoscopic cholecystectomy: low risk for
pulmonary embolism. Some clients develop pain from carbon dioxide retention in the
abdomen following a laparoscopic cholecystectomy. There is another client who is at
greater risk for developing a pulmonary embolism.
• A nurse is caring for a newly admitted client who has emphysema. The nurse should place
the client in which of the following positions to promote effective breathing?
• Lateral position with a pillow at the back and over the chest to support the arm:
promotes alignment of the back and can be good position for sleeping. However,
this position does not promote maximum chest expansion to facilitate breathing
• High-Fowler’s position with the arms supported on the overbed table (Correct) –
allows greater expansion of the chest, such as sitting up right and leaning slightly
forward while supporting both arms with pillows for comfort on the overbed table
• Semi-Fowler’s position with pillows supporting both arms: Has the head and
truck elevated to a 30-45 degree angle, does not promote maximum chest
expansion to facilitate breathing
• Supine position with the head of the ed elevated to 15 degrees: allows the
diaphragm and abdominal organs to place pressure on the thoracic cavity and
compromise chest expansion. This position does not promote maximum chest
expansion to facilitate breathing.
• A nurse is caring for a client who had asthma and is receiving albuterol. For which of the
following adverse effects should the nurse monitor the client?
• Hyperkalemia: monitor; potential adverse effect
• Dyspnea: monitor for a decrease in dyspnea; decrease is a therapeutic effect, not
an adverse
• Tachycardia (Correct) – monitor; common adverse effect of this medication,
especially if the client uses albuterol on a regular basis
• Candidiasis: monitor who is taking an inhaled glucocorticoid, such as
beclomethasone, for candidiasis
• A nurse is preparing a client for discharge following a bronchoscopy with the use of
moderate sedation. The nurse should identify that which of the following assessments is
the priority?
• Presence of gag reflex (Correct) – greatest risk (aspiration) due to depressed gag reflex.
Therefore, the priority assessment by the nurse is to determine the return of the gag
reflex
• Pain level rating using a 0-10 scale: risk for increased pain because of the introduction
of the scope into the trachea. However, another assessment is the priority
