ATI MED SURG BASIC CAREAND COMFORT EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS
AGRADE
Question 1 See full question
Two days after a herniorrhaphy, the client reports that his scrotum is swollen and
painful. To promote comfort, the nurse should instruct the client to:
You Selected:
• elevate the scrotum and place ice bags on the area intermittently.
Correct response:
• elevate the scrotum and place ice bags on the area intermittently.
Explanation:
A swollen, painful scrotum after herniorrhaphy is relatively common. Elevating the
scrotum, as on a rolled towel, and intermittently placing ice bags on the area are helpful.
Applying an abdominal binder will have no effect on the scrotal swelling.
Applying a truss is unlikely to promote comfort when the scrotum is swollen.
Having the client lie on his side with a pillow between his legs will not elevate the
scrotum; therefore, this will not help reduce swelling and discomfort.
Question 2 See full question
The nurse is preparing the client with heart failure to go home. The nurse should instruct
the client to:
You Selected:
• monitor weight daily.
Correct response:
• monitor weight daily.
Explanation:
People with heart failure are taught to maintain a target weight and to weigh themselves
daily to monitor increasing fluid retention. Fluid retention can lead to decompensation
and hospitalization.
Monitoring daily urine output is not required of these clients.
,A week of bed rest is not indicated for most people with heart failure.
,Clients on potassium-wasting diuretics will be taught to include dietary sources of
potassium or to take a potassium supplement. However, all clients with heart failure
should weigh themselves daily to monitor fluid status.
Question 3 See full question
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse
should:
You Selected:
• stay with the client and encourage him to eat.
Correct response:
• stay with the client and encourage him to eat.
Explanation:
Staying with the client and encouraging him to feed himself will ensure adequate food
intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during
meals, filling out the menu, or helping the client to complete the menu doesn't ensure
adequate nutritional intake.
Question 4 See full question
The nurse teaches a client who has recently been diagnosed with hypertension about
following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet
the client's needs?
You Selected:
• baked chicken, an apple, and a slice of white bread
Correct response:
• baked chicken, an apple, and a slice of white bread
Explanation:
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high
in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet.
Dietary restrictions of all types are complex and difficult to implement with clients who
are basically asymptomatic.
Question 5 See full question
The nurse is performing a nutrition assessment of a client from the Middle East. What
may the nurse expect as a traditional breakfast consumed by a client from the Middle
East?
, You Selected:
• Cheese and olives.
Correct response:
• Cheese and olives.
Explanation:
People from Middle Eastern countries often eat cheese and olives for breakfast.
Question 1 See full question
As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night."
Which action should the nurse take first?
You Selected:
• Gathering more information about the client's sleep problem
Correct response:
• Gathering more information about the client's sleep problem
Explanation:
The nurse first should determine what the client means by "trouble sleeping." The nurse
lacks sufficient information to recommend warm milk or a warm shower or to make
inferences about the cause of the sleep problem, such as worries or medication use.
Question 2 See full question
While caring for a client who's immobile, a nurse documents the following information in
the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no
redness noted." "Client up in chair three times today." "Improved skin turgor noted."
Which nursing diagnosis accurately reflects this information?
You Selected:
• Risk for impaired skin integrity related to immobility
Correct response:
• Risk for impaired skin integrity related to immobility
QUESTIONS AND CORRECT DETAILED ANSWERS
AGRADE
Question 1 See full question
Two days after a herniorrhaphy, the client reports that his scrotum is swollen and
painful. To promote comfort, the nurse should instruct the client to:
You Selected:
• elevate the scrotum and place ice bags on the area intermittently.
Correct response:
• elevate the scrotum and place ice bags on the area intermittently.
Explanation:
A swollen, painful scrotum after herniorrhaphy is relatively common. Elevating the
scrotum, as on a rolled towel, and intermittently placing ice bags on the area are helpful.
Applying an abdominal binder will have no effect on the scrotal swelling.
Applying a truss is unlikely to promote comfort when the scrotum is swollen.
Having the client lie on his side with a pillow between his legs will not elevate the
scrotum; therefore, this will not help reduce swelling and discomfort.
Question 2 See full question
The nurse is preparing the client with heart failure to go home. The nurse should instruct
the client to:
You Selected:
• monitor weight daily.
Correct response:
• monitor weight daily.
Explanation:
People with heart failure are taught to maintain a target weight and to weigh themselves
daily to monitor increasing fluid retention. Fluid retention can lead to decompensation
and hospitalization.
Monitoring daily urine output is not required of these clients.
,A week of bed rest is not indicated for most people with heart failure.
,Clients on potassium-wasting diuretics will be taught to include dietary sources of
potassium or to take a potassium supplement. However, all clients with heart failure
should weigh themselves daily to monitor fluid status.
Question 3 See full question
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse
should:
You Selected:
• stay with the client and encourage him to eat.
Correct response:
• stay with the client and encourage him to eat.
Explanation:
Staying with the client and encouraging him to feed himself will ensure adequate food
intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during
meals, filling out the menu, or helping the client to complete the menu doesn't ensure
adequate nutritional intake.
Question 4 See full question
The nurse teaches a client who has recently been diagnosed with hypertension about
following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet
the client's needs?
You Selected:
• baked chicken, an apple, and a slice of white bread
Correct response:
• baked chicken, an apple, and a slice of white bread
Explanation:
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high
in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet.
Dietary restrictions of all types are complex and difficult to implement with clients who
are basically asymptomatic.
Question 5 See full question
The nurse is performing a nutrition assessment of a client from the Middle East. What
may the nurse expect as a traditional breakfast consumed by a client from the Middle
East?
, You Selected:
• Cheese and olives.
Correct response:
• Cheese and olives.
Explanation:
People from Middle Eastern countries often eat cheese and olives for breakfast.
Question 1 See full question
As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night."
Which action should the nurse take first?
You Selected:
• Gathering more information about the client's sleep problem
Correct response:
• Gathering more information about the client's sleep problem
Explanation:
The nurse first should determine what the client means by "trouble sleeping." The nurse
lacks sufficient information to recommend warm milk or a warm shower or to make
inferences about the cause of the sleep problem, such as worries or medication use.
Question 2 See full question
While caring for a client who's immobile, a nurse documents the following information in
the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no
redness noted." "Client up in chair three times today." "Improved skin turgor noted."
Which nursing diagnosis accurately reflects this information?
You Selected:
• Risk for impaired skin integrity related to immobility
Correct response:
• Risk for impaired skin integrity related to immobility
