MED SURG 3 480 ATI FINAL EXAM
VERSION B QUESTIONS AND ANSWERS
2025/2026 | 100% CORRECT | West Coast
University
• A triage nurse in an emergency dept is caring for a client who
has gunshot wound to the right side of chest. The nurse notices
thick dressing on the chest and sucking noise coming from the
wound. The client has a blood pressure of 100/60 mm Hg, a weak
pulse rate of 118/min, and a respiratory rate of 40/min. Which of
the following actions should the nurse take initially?
a. Raise the foot of the bed to a 90 degree angle
b. Remove the dressing to inspect the wound???
c. Prepare to insert a central line
d.Administer oxygen via nasal cannula???
• A nurse is suctioning the endotracheal tube of a client who is on
a ventilator. The client’s heart rate increases from 86/min to
110/min and becomes irregular. The nurse should know that the
client requires which of the following?
a. A cardiology consult
,b. Less frequent suctioning
c. An antidysrhythmic medication
d.Pre-oxygenation prior to suctioning
• The nurse is caring for a client who is receiving a blood
transfusion. The transfusion started 30 minutes ago at a rate of
100 mL/hr. The client begins to complain of low back pain and
headache and is increasingly restless. What is the first nursing
action?
a. Stop the transfusion, disconnect the blood
tubing, and begin a primary infusion of normal
saline solution
b. Slow the infusion and evaluate the vital signs and the
client’s history of tranfusion reactions
c.Slow the infusion of blood and begin infusion of normal
saline solution from the Y connector.
d. Recheck the unit of blood for correct
,identification numbers and crossmatch information
• A client with a diagnosis of disseminated intravascular
coagulation (DIC) has the following assessment findings: blood
pressure of 76/56, temperature 102.6 degrees, resp. 24
breath/min., with complaints of severe neck and back pain.
Which nursing action should the nurse implement first?
a. Administer acetaminophen (Tylenol) PO.
b. Administer ibuprofen (Motrin) PO.
c.Draw coagulation study blood work in the AM
d. Give morphine sulfate IV
• The nurse administering albuterol (Proventil) via a metered-
dose inhaler (MDI) to a client who has a history of coronary artery
disease is now in congestive heart failure. What side effects will be
, particularly important to observe for when the client takes the
medication?
VERSION B QUESTIONS AND ANSWERS
2025/2026 | 100% CORRECT | West Coast
University
• A triage nurse in an emergency dept is caring for a client who
has gunshot wound to the right side of chest. The nurse notices
thick dressing on the chest and sucking noise coming from the
wound. The client has a blood pressure of 100/60 mm Hg, a weak
pulse rate of 118/min, and a respiratory rate of 40/min. Which of
the following actions should the nurse take initially?
a. Raise the foot of the bed to a 90 degree angle
b. Remove the dressing to inspect the wound???
c. Prepare to insert a central line
d.Administer oxygen via nasal cannula???
• A nurse is suctioning the endotracheal tube of a client who is on
a ventilator. The client’s heart rate increases from 86/min to
110/min and becomes irregular. The nurse should know that the
client requires which of the following?
a. A cardiology consult
,b. Less frequent suctioning
c. An antidysrhythmic medication
d.Pre-oxygenation prior to suctioning
• The nurse is caring for a client who is receiving a blood
transfusion. The transfusion started 30 minutes ago at a rate of
100 mL/hr. The client begins to complain of low back pain and
headache and is increasingly restless. What is the first nursing
action?
a. Stop the transfusion, disconnect the blood
tubing, and begin a primary infusion of normal
saline solution
b. Slow the infusion and evaluate the vital signs and the
client’s history of tranfusion reactions
c.Slow the infusion of blood and begin infusion of normal
saline solution from the Y connector.
d. Recheck the unit of blood for correct
,identification numbers and crossmatch information
• A client with a diagnosis of disseminated intravascular
coagulation (DIC) has the following assessment findings: blood
pressure of 76/56, temperature 102.6 degrees, resp. 24
breath/min., with complaints of severe neck and back pain.
Which nursing action should the nurse implement first?
a. Administer acetaminophen (Tylenol) PO.
b. Administer ibuprofen (Motrin) PO.
c.Draw coagulation study blood work in the AM
d. Give morphine sulfate IV
• The nurse administering albuterol (Proventil) via a metered-
dose inhaler (MDI) to a client who has a history of coronary artery
disease is now in congestive heart failure. What side effects will be
, particularly important to observe for when the client takes the
medication?
