ATI RN ADULT MEDICAL SURGICAL 2023 FOR NGN FORM
A, B & C ACTUAL EXAM EACH FORM CONTAINS 100
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
|ALREADY GRADED A+
FORM A
A nurse in an acute care facility is caring for a client who is at risk for seizures.
Which of the following precautions should the nurse implement? - ANSWER-
Ensure the client has a patient IV.
RATIONALE: The nurse should ensure the client has IV access in the event that
the client requires medication to stop seizure activity.
A nurse is caring for a client who is postoperative following a total hip
arthroplasty. Which of the following laboratory values should the nurse report to
the provider? - ANSWER- Hgb 8 g/dL
RATIONALE: The nurse should report an Hgb level of 8 g/dL, which is below
the expected reference range and is an indicator of postoperative hemorrhage or
anemia.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy
(ESWL) 6 hr ago. Which of the following findings should the nurse expect? -
ANSWER- Stone fragments in the urine
RATIONALE: ESWL is an effort to break the calculi so that the fragments pass
down the ureter, into the bladder, and through the urethra during voiding.
Following the procedure, the nurse should strain the client's urine to confirm the
passage of stones.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and
a productive cough. Which of the following actions should the nurse take first? -
ANSWER- Initiate airborne precautions.
RATIONALE: This client is exhibiting manifestations of tuberculosis. The
greatest risk in this client situation is for other people in the facility to acquire an
airborne disease from this client. Therefore, the first action the nurse should take is
to initiate airborne precautions.
,A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A
new bag is not available when the current infusion is nearly completed. Which of
the following actions should the nurse take? - ANSWER- Administer dextrose
10% in water until the new bag arrives.
RATIONALE: TPN solutions have a high concentration of dextrose. Therefore,
if a TPN solution is temporarily unavailable, the nurse should administer dextrose
10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following
supplements can interfere with the effectiveness of the medication? - ANSWER-
Calcium
RATIONALE: Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can interfere with
the metabolism of a number of medications, including levothyroxine. The nurse
should instruct the client to avoid taking calcium within 4 hr of levothyroxine
administration.
A nurse is caring for a client who has emphysema and is receiving mechanical
ventilation. The client appears anxious and restless, and the high-pressure alarm is
sounding. Which of the following actions should the nurse take first? - ANSWER-
Instruct the client to allow the machine to breathe for them.
RATIONALE: When providing client care, the nurse should first use the least
restrictive intervention. Therefore, the first action the nurse should take is to
provide verbal instructions and emotional support to help the client relax and allow
the ventilator to work. Clients can exhibit anxiety and restlessness when trying to
"fight the ventilator."
A nurse is caring for a client who has a prescription for enalapril. The nurse should
identify which of the following findings as an adverse effect of the medication? -
ANSWER- Orthostatic hypotension
RATIONALE: The nurse should identify that dilation of arteries and veins causes
orthostatic hypotension, which is an adverse effect of enalapril.
,A nurse is caring for a client who has a stage III pressure injury. Which of the
following findings contributes to delayed wound healing? - ANSWER- Urine
output 25 mL/hr
RATIONALE: Urinary output reflects fluid status. Inadequate urine output can
indicate dehydration, which can delay wound healing.
A nurse is providing teaching to an older adult client who has cancer and a new
prescription for an opioid analgesic for pain management. Which of the following
information should the nurse include in the teaching? - ANSWER- "You should
void every 4 hours to decrease the risk of urinary retention."
RATIONALE: The nurse should instruct the client to void at least every 4 hr to
decrease the risk of urinary retention, which is an adverse effect of opioid
analgesics.
A nurse is caring for a client who has portal hypertension. The client is vomiting
blood mixed with food after a meal. Which of the following actions should the
nurse take first? - ANSWER- Obtain vital signs.
RATIONALE: The first action the nurse should take using the nursing process is
to assess the client's vital signs. A client who has portal hypertension can develop
esophageal varices, which are fragile and can rupture, resulting in large amounts of
blood loss and shock. Obtaining vital signs provides information about the client's
condition that can contribute to decision making.
A nurse at a provider's office is caring for a client who is 2 weeks postoperative
following a gastrectomyA nurse is providing teaching for the client. Which of the
following instructions should the nurse include? - ANSWER- Avoid drinking
fluids with meals
Eat several small meals per day
Consume high-protein snacks
Avoid highly seasoned foods
RATIONALE: Maintain a high carbohydrate intake is incorrect. Dumping
syndrome requires a low carbohydrate diet because of reactive hypoglycemia.
Eat five servings of fresh fruit per day is incorrect. The client should limit intake to
three servings of unsweetened cooked or canned fruit per day.
Avoid drinking fluids with meals is correct. The nurse should instruct the client to
drink fluids 30 min before or after meals.
, Eat several small meals per day is correct. The nurse should instruct the client to
eat several small, frequent meals instead of three large meals per day.
Consume high-protein snacks is correct. The client should eat snacks that are high
in protein and low in carbohydrates to prevent the gastric food boluses and reactive
hypoglycemia in dumping syndrome.
Avoid highly seasoned foods is correct. The nurse should instruct the client to
avoid excessive amounts of spices and salt.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of
the following findings should the nurse identify as a component of Cushing's triad?
- ANSWER- Bradycardia
RATIONALE: A client who has increased intracranial pressure from a traumatic
brain injury can develop bradycardia, which is one component of Cushing's triad.
The other components of Cushing's triad are severe hypertension and a widened
pulse pressure.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus.
Which of the following client statements indicates the client is successfully coping
with the change? - ANSWER- "I used to never worry about my feet. Now, I
inspect my feet every day with a mirror."
RATIONALE: This statement indicates that the client is successfully coping with
the change because the client is performing preventive foot care to reduce the risk
for complications.
A nurse is assessing a male client for an inguinal hernia. Which of the following
areas should the nurse palpate to verify that the client has an inguinal hernia? (You
will find hot spots to select in the artwork below. Select only the hot spot that
corresponds to your answer.) - ANSWER- C
A is incorrect. The nurse should palpate this location to assess the client for a
femoral hernia. A femoral hernia is composed of fat and forms in the femoral
canal, which, as a result, enlarges and pulls on the peritoneum and sometimes the
bladder.B is incorrect. The nurse should palpate this location to assess the client for
an umbilical hernia. This type of hernia can be congenital or acquired as a result of
pregnancy or obesity and places increased pressure on the abdominal wall.C is
correct. The nurse should palpate this location to assess the client for an inguinal
hernia. An inguinal hernia forms from the peritoneum, which contains part of the
intestine, and can protrude into the scrotum in men.
A, B & C ACTUAL EXAM EACH FORM CONTAINS 100
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES
|ALREADY GRADED A+
FORM A
A nurse in an acute care facility is caring for a client who is at risk for seizures.
Which of the following precautions should the nurse implement? - ANSWER-
Ensure the client has a patient IV.
RATIONALE: The nurse should ensure the client has IV access in the event that
the client requires medication to stop seizure activity.
A nurse is caring for a client who is postoperative following a total hip
arthroplasty. Which of the following laboratory values should the nurse report to
the provider? - ANSWER- Hgb 8 g/dL
RATIONALE: The nurse should report an Hgb level of 8 g/dL, which is below
the expected reference range and is an indicator of postoperative hemorrhage or
anemia.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy
(ESWL) 6 hr ago. Which of the following findings should the nurse expect? -
ANSWER- Stone fragments in the urine
RATIONALE: ESWL is an effort to break the calculi so that the fragments pass
down the ureter, into the bladder, and through the urethra during voiding.
Following the procedure, the nurse should strain the client's urine to confirm the
passage of stones.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and
a productive cough. Which of the following actions should the nurse take first? -
ANSWER- Initiate airborne precautions.
RATIONALE: This client is exhibiting manifestations of tuberculosis. The
greatest risk in this client situation is for other people in the facility to acquire an
airborne disease from this client. Therefore, the first action the nurse should take is
to initiate airborne precautions.
,A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A
new bag is not available when the current infusion is nearly completed. Which of
the following actions should the nurse take? - ANSWER- Administer dextrose
10% in water until the new bag arrives.
RATIONALE: TPN solutions have a high concentration of dextrose. Therefore,
if a TPN solution is temporarily unavailable, the nurse should administer dextrose
10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.
A nurse is providing teaching to a client who has hypothyroidism and is receiving
levothyroxine. The nurse should instruct the client that which of the following
supplements can interfere with the effectiveness of the medication? - ANSWER-
Calcium
RATIONALE: Calcium limits the development of osteoporosis in clients who are
postmenopausal and works as an antacid. Calcium supplements can interfere with
the metabolism of a number of medications, including levothyroxine. The nurse
should instruct the client to avoid taking calcium within 4 hr of levothyroxine
administration.
A nurse is caring for a client who has emphysema and is receiving mechanical
ventilation. The client appears anxious and restless, and the high-pressure alarm is
sounding. Which of the following actions should the nurse take first? - ANSWER-
Instruct the client to allow the machine to breathe for them.
RATIONALE: When providing client care, the nurse should first use the least
restrictive intervention. Therefore, the first action the nurse should take is to
provide verbal instructions and emotional support to help the client relax and allow
the ventilator to work. Clients can exhibit anxiety and restlessness when trying to
"fight the ventilator."
A nurse is caring for a client who has a prescription for enalapril. The nurse should
identify which of the following findings as an adverse effect of the medication? -
ANSWER- Orthostatic hypotension
RATIONALE: The nurse should identify that dilation of arteries and veins causes
orthostatic hypotension, which is an adverse effect of enalapril.
,A nurse is caring for a client who has a stage III pressure injury. Which of the
following findings contributes to delayed wound healing? - ANSWER- Urine
output 25 mL/hr
RATIONALE: Urinary output reflects fluid status. Inadequate urine output can
indicate dehydration, which can delay wound healing.
A nurse is providing teaching to an older adult client who has cancer and a new
prescription for an opioid analgesic for pain management. Which of the following
information should the nurse include in the teaching? - ANSWER- "You should
void every 4 hours to decrease the risk of urinary retention."
RATIONALE: The nurse should instruct the client to void at least every 4 hr to
decrease the risk of urinary retention, which is an adverse effect of opioid
analgesics.
A nurse is caring for a client who has portal hypertension. The client is vomiting
blood mixed with food after a meal. Which of the following actions should the
nurse take first? - ANSWER- Obtain vital signs.
RATIONALE: The first action the nurse should take using the nursing process is
to assess the client's vital signs. A client who has portal hypertension can develop
esophageal varices, which are fragile and can rupture, resulting in large amounts of
blood loss and shock. Obtaining vital signs provides information about the client's
condition that can contribute to decision making.
A nurse at a provider's office is caring for a client who is 2 weeks postoperative
following a gastrectomyA nurse is providing teaching for the client. Which of the
following instructions should the nurse include? - ANSWER- Avoid drinking
fluids with meals
Eat several small meals per day
Consume high-protein snacks
Avoid highly seasoned foods
RATIONALE: Maintain a high carbohydrate intake is incorrect. Dumping
syndrome requires a low carbohydrate diet because of reactive hypoglycemia.
Eat five servings of fresh fruit per day is incorrect. The client should limit intake to
three servings of unsweetened cooked or canned fruit per day.
Avoid drinking fluids with meals is correct. The nurse should instruct the client to
drink fluids 30 min before or after meals.
, Eat several small meals per day is correct. The nurse should instruct the client to
eat several small, frequent meals instead of three large meals per day.
Consume high-protein snacks is correct. The client should eat snacks that are high
in protein and low in carbohydrates to prevent the gastric food boluses and reactive
hypoglycemia in dumping syndrome.
Avoid highly seasoned foods is correct. The nurse should instruct the client to
avoid excessive amounts of spices and salt.
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of
the following findings should the nurse identify as a component of Cushing's triad?
- ANSWER- Bradycardia
RATIONALE: A client who has increased intracranial pressure from a traumatic
brain injury can develop bradycardia, which is one component of Cushing's triad.
The other components of Cushing's triad are severe hypertension and a widened
pulse pressure.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus.
Which of the following client statements indicates the client is successfully coping
with the change? - ANSWER- "I used to never worry about my feet. Now, I
inspect my feet every day with a mirror."
RATIONALE: This statement indicates that the client is successfully coping with
the change because the client is performing preventive foot care to reduce the risk
for complications.
A nurse is assessing a male client for an inguinal hernia. Which of the following
areas should the nurse palpate to verify that the client has an inguinal hernia? (You
will find hot spots to select in the artwork below. Select only the hot spot that
corresponds to your answer.) - ANSWER- C
A is incorrect. The nurse should palpate this location to assess the client for a
femoral hernia. A femoral hernia is composed of fat and forms in the femoral
canal, which, as a result, enlarges and pulls on the peritoneum and sometimes the
bladder.B is incorrect. The nurse should palpate this location to assess the client for
an umbilical hernia. This type of hernia can be congenital or acquired as a result of
pregnancy or obesity and places increased pressure on the abdominal wall.C is
correct. The nurse should palpate this location to assess the client for an inguinal
hernia. An inguinal hernia forms from the peritoneum, which contains part of the
intestine, and can protrude into the scrotum in men.
