MED SURG ATI PRACTICE A 2023
QUESTIONS WITH 100% CORRRECT
ANSWERS,.
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
"You will have an implant placed twice each month for the duration of the treatment."
"You should remain at least 6 feet away from others between treatments."
"You should expect to have blood in your urine for a few days after treatment."
"You will need to stay still in the bed during each treatment session." ANSWER : -"You will need to stay
still in the bed during each treatment session."
The nurse should instruct the client that they will need to remain on bed rest with very limited
movement because excessive movement can cause the radioactive source to become dislodged.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the
past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing
fluid volume deficit?
Heart rate 110/min
Blood pressure 138/90 mm Hg
Urine specific gravity 1.020
BUN 15 mg/dL ANSWER : -Heart rate 110/min
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an
elevated heart rate.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these
treatments. I am ready to die." Which of the following statements should the nurse make?
,"Discontinuing with the treatments is your choice if it is your wish to do so."
"Your child is named as your health care surrogate. I will ask them if you can stop the treatments."
"I will call your spiritual advisor to come in, so you can discuss this with them."
"Next time you have an oncology appointment, you should ask the oncologist." ANSWER : -
"Discontinuing with the treatments is your choice if it is your wish to do so."
The nurse should recognize the client's right to refuse the treatments and inform the client of this right.
The nurse should advocate for the client and offer to contact the provider for the client.
A nurse is caring for a client who is receiving dialysis treatment..
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
ANSWER : -INDICATED:
- Apply oxygen at 2 L/min via nasal cannula.
- Administer a 0.9% sodium chloride 200 mL IV bolus.
- Notify the provider immediately.
- Place the client in Trendelenburg position.
NOT INDICATED:
- Perform a 12-lead ECG.
- Obtain the client's blood glucose level.
A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take?
Select all that apply. ANSWER : -- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Report urinary output to the provider
- Ask the client to rate their pain on a 0 to 10 pain scale
Rationale:
- It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory
complications and reduce the risk of complications to the surgical incision.
,- The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease
the risk of thrombosis.
- The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this
finding to the provider.
- The nurse should have the client rate their pain prior to and following the administration of pain
medication to evaluate its effectiveness.
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?
1. Keep the line open with 0.9% sodium chloride until the new bag arrives.
2. Administer dextrose 10% in water until the new bag arrives.
3. Flush the line and cap the port until the new bag arrives.
4. Decrease the infusion rate until the new bag arrives. ANSWER : -2. Administer dextrose 10% in water
until the new bag arrives.
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 caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following
findings should the nurse report to the provider?
1. The client's urinary output has increased.
2. The client reports back pain.
3. The client's urine color is red tinged.
4. The client's BUN is 18 mg/dL. ANSWER : -2. The client reports back pain.
The nurse should notify the provider if the client reports back pain, which can indicate that the
nephrostomy tube is dislodged or clogged.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's
priority?
1. Loosen the clothing around the client's neck.
, 2. Check the client's pupillary response.
3. Turn the client to the side.
4. Move furniture away from the client. ANSWER : -3. Turn the client to the side.
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention
the nurse should take is to place the client in a side-lying position to prevent aspiration.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of
the following findings should indicate to the nurse that the client is experiencing an adverse reaction to
this medication?
1. Report of a night cough
2. Report of tinnitus
3. Report of excessive tearing
4. Report of increased salivation ANSWER : -1. Report of a night cough
The nurse should recognize that a night cough is an early indication of heart failure and report this
adverse reaction to the provider.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
Apply a wet-to-dry gauze dressing.
Irrigate with hydrogen peroxide solution.
Use a 30-mL syringe.
Attach a 24-gauge angiocatheter to the syringe. ANSWER : -Use a 30-mL syringe.
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal
pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation
tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to
the nurse that the client has exophthalmos? ANSWER : -Eyes bulging and wide open
QUESTIONS WITH 100% CORRRECT
ANSWERS,.
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
"You will have an implant placed twice each month for the duration of the treatment."
"You should remain at least 6 feet away from others between treatments."
"You should expect to have blood in your urine for a few days after treatment."
"You will need to stay still in the bed during each treatment session." ANSWER : -"You will need to stay
still in the bed during each treatment session."
The nurse should instruct the client that they will need to remain on bed rest with very limited
movement because excessive movement can cause the radioactive source to become dislodged.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the
past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing
fluid volume deficit?
Heart rate 110/min
Blood pressure 138/90 mm Hg
Urine specific gravity 1.020
BUN 15 mg/dL ANSWER : -Heart rate 110/min
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an
elevated heart rate.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these
treatments. I am ready to die." Which of the following statements should the nurse make?
,"Discontinuing with the treatments is your choice if it is your wish to do so."
"Your child is named as your health care surrogate. I will ask them if you can stop the treatments."
"I will call your spiritual advisor to come in, so you can discuss this with them."
"Next time you have an oncology appointment, you should ask the oncologist." ANSWER : -
"Discontinuing with the treatments is your choice if it is your wish to do so."
The nurse should recognize the client's right to refuse the treatments and inform the client of this right.
The nurse should advocate for the client and offer to contact the provider for the client.
A nurse is caring for a client who is receiving dialysis treatment..
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
ANSWER : -INDICATED:
- Apply oxygen at 2 L/min via nasal cannula.
- Administer a 0.9% sodium chloride 200 mL IV bolus.
- Notify the provider immediately.
- Place the client in Trendelenburg position.
NOT INDICATED:
- Perform a 12-lead ECG.
- Obtain the client's blood glucose level.
A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take?
Select all that apply. ANSWER : -- Instruct the client to splint the abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Report urinary output to the provider
- Ask the client to rate their pain on a 0 to 10 pain scale
Rationale:
- It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory
complications and reduce the risk of complications to the surgical incision.
,- The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease
the risk of thrombosis.
- The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this
finding to the provider.
- The nurse should have the client rate their pain prior to and following the administration of pain
medication to evaluate its effectiveness.
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?
1. Keep the line open with 0.9% sodium chloride until the new bag arrives.
2. Administer dextrose 10% in water until the new bag arrives.
3. Flush the line and cap the port until the new bag arrives.
4. Decrease the infusion rate until the new bag arrives. ANSWER : -2. Administer dextrose 10% in water
until the new bag arrives.
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 caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following
findings should the nurse report to the provider?
1. The client's urinary output has increased.
2. The client reports back pain.
3. The client's urine color is red tinged.
4. The client's BUN is 18 mg/dL. ANSWER : -2. The client reports back pain.
The nurse should notify the provider if the client reports back pain, which can indicate that the
nephrostomy tube is dislodged or clogged.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's
priority?
1. Loosen the clothing around the client's neck.
, 2. Check the client's pupillary response.
3. Turn the client to the side.
4. Move furniture away from the client. ANSWER : -3. Turn the client to the side.
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention
the nurse should take is to place the client in a side-lying position to prevent aspiration.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of
the following findings should indicate to the nurse that the client is experiencing an adverse reaction to
this medication?
1. Report of a night cough
2. Report of tinnitus
3. Report of excessive tearing
4. Report of increased salivation ANSWER : -1. Report of a night cough
The nurse should recognize that a night cough is an early indication of heart failure and report this
adverse reaction to the provider.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure
injury. Which of the following actions should the nurse take?
Apply a wet-to-dry gauze dressing.
Irrigate with hydrogen peroxide solution.
Use a 30-mL syringe.
Attach a 24-gauge angiocatheter to the syringe. ANSWER : -Use a 30-mL syringe.
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal
pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation
tissue, the wound irrigation should be delivered at between 4 and 15 psi.
A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to
the nurse that the client has exophthalmos? ANSWER : -Eyes bulging and wide open
