ATI MEDICAL SURGICAL EXAM QUESTIONS AND
100% C0RRECT ANSWERS/MEDICAL SURGICAL
. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. D. Basilar crackles
E. Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the
lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance
because the patient is retaining secretions.
Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation
D. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with
pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include
dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the
secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also
helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also
be helpful, but does not liquefy the secretions so that they can be removed.
. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
,B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung
disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
most effective when the patient states which of the following measures to prevent a relapse? A. "I
will increase my food intake to 2400 calories a day to keep my immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important
for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory
infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below
normal.
. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity
D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivity
was sent to the laboratory before administering the cefotetan. It is important that the organisms are
correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also
determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic
administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of
the other options will not be affected by the administration of antibiotics.
. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease? A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for
the patient assuring stable oxygenation status. Research indicates that positioning the patient with the
,unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung
disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing
fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most
appropriate to enhance oxygenation.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient?
A. Delay any physical assessment of the patient and review with the family the patient's history
of respiratory problems. B. Perform a comprehensive health history with the patient to review
prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory distress on other
body functions.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask
specific questions about this episode and perform a physical assessment of this system. Further history
taking and physical examination of other body systems can proceed once the patient's acute
respiratory distress is being managed.
. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-
pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased
the patient's underlying respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in
impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation
from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these
findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during
activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
An oxygen saturation level that drops below 90% with activity indicates that the patient is not
tolerating the exercise and needs to have supplemental oxygen applied.
, The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third
postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something
is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91%
on room air. Which of the following should the nurse first suspect as the etiology of this episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room
B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of
pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions
should the nurse take first?
A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen.
D. Sit the patient up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason,
the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The
physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the
nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with use of a contrast
dye.
C. This test will use magnetic fields to produce images of the lungs and chest.
D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs.
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas
.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the
blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a
radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea.
The nurse interprets that these symptoms are related to which of the following pathophysiologic
changes?
A. Laryngospasm B. Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema
100% C0RRECT ANSWERS/MEDICAL SURGICAL
. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. D. Basilar crackles
E. Basilar crackles
The presence of adventitious breath sounds indicates that there is accumulation of secretions in the
lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance
because the patient is retaining secretions.
Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation
D. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with
pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include
dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the
secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also
helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also
be helpful, but does not liquefy the secretions so that they can be removed.
. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
,B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung
disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
most effective when the patient states which of the following measures to prevent a relapse? A. "I
will increase my food intake to 2400 calories a day to keep my immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important
for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory
infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below
normal.
. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity
D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivity
was sent to the laboratory before administering the cefotetan. It is important that the organisms are
correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also
determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic
administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of
the other options will not be affected by the administration of antibiotics.
. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease? A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for
the patient assuring stable oxygenation status. Research indicates that positioning the patient with the
,unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung
disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing
fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most
appropriate to enhance oxygenation.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient?
A. Delay any physical assessment of the patient and review with the family the patient's history
of respiratory problems. B. Perform a comprehensive health history with the patient to review
prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory distress on other
body functions.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this
episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask
specific questions about this episode and perform a physical assessment of this system. Further history
taking and physical examination of other body systems can proceed once the patient's acute
respiratory distress is being managed.
. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-
pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased
the patient's underlying respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in
impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation
from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these
findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during
activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
An oxygen saturation level that drops below 90% with activity indicates that the patient is not
tolerating the exercise and needs to have supplemental oxygen applied.
, The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third
postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something
is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91%
on room air. Which of the following should the nurse first suspect as the etiology of this episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room
B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of
pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions
should the nurse take first?
A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen.
D. Sit the patient up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason,
the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The
physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the
nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with use of a contrast
dye.
C. This test will use magnetic fields to produce images of the lungs and chest.
D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs.
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas
.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the
blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a
radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea.
The nurse interprets that these symptoms are related to which of the following pathophysiologic
changes?
A. Laryngospasm B. Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema
