MedSurge ATI Exam
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1. A nurse is caring for a client who is receiving dialysis treatment.
Nurses' Notes
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultat-
ed for bruit. Lung sounds clear upon auscultation; client denies shortness of
breath. No peripheral edema noted; capillary refill is less than 3 seconds; +2
bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped
and secured; treatment is initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports
no discomfort or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and
slightly confused.
Vital Signs
0530:
Weight 88 kg (194 lb)
Temperature 37° C (98.6° F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure
Sitting - 148/90 mm Hg
Standing - 144/88 mm Hg
Oxygen saturation 98% on room air0600:
B: Place the client in Trendelenburg position
Administer a 0.9% sodium chloride 200 mL IV bolus
Apply oxygen at 2 L/min via nasal cannula
Notify the provider immediately
2. A nurse is caring for a client who is postoperative following abdominal
surgery.
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client is drowsy,
but arouses to verbal stimuli. Oriented x3, moves all extremities. Normal
sinus rhythm. Chest clear. Dressing to abdomen intact, small amount of
serosanguinous drainage noted and marked. No bowel sounds x 4 quadrants.
Indwelling urinary catheter in place, draining clear yellow urine. Lactated
Ringer's infusing at 100 mL/hr via IV catheter to right forearm.1200:
Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing
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intact, no further drainage noted. Urine output 15 mL since arrival from PACU.
Analgesic and antiemetic administered as prescribed.1230:
Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO2 96%.
Repositioned for comfort. Encouraged to turn, cough, and deep breathe.1300:
No additional urin: 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 scale of 0-10
3. A nurse is caring for a client who is receiving total parental nutrition (TPN). A
new bag is not available when the current infusion is nearly completed. Which
of the following actions should the nurse take?
Keep the line open with 0.9% sodium chloride until the new bag arrives.
Administer dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.: Administer dextrose 10%
in water until the new bag arrives.
4. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr
ago. Which of the following findings indicates a potential complication?
The client's urinary output has increased.
The client reports back pain.
The client's urine color is red tinged.
The client's tube requires irrigation.: The client reports back pain
5. A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
Loosen the clothing around the client's neck.
Check the client's pupillary response.
Turn the client to the side.
Move furniture away from the client.: Turn the client to the side
6. 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?
Report of a night cough
Report of tinnitus
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Report of excessive tearing
Report of increased salivation: Report of a night cough
7. 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.: Use a 30-mL syringe
8. A nurse is assessing a client who has Graves' disease. Which of the follow-
ing images should indicate to the nurse that the client has exophthalmos?: -
Bulging or protruding eyes
9. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which
of the following should indicate to the nurse that the client's condition is
improving?
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
pH 7.28 (7.35 to 7.45)
Glucose 272 mg/dL (74 to 106 mg/dL)
HCO3- 14 mEq/L (21 to 28 mEq/L): Glucose 272 mg/dL
10. A nurse is caring for a client who has hypothyroidism. Which of the follow-
ing manifestations should the nurse expect?
Constipation
Insomnia
Tachycardia
Diaphoresis: Constiptation
11. A nurse is prepare to administer a blood transfusion to a client who has
anemia. Which of the following actions should the nurse take first?
Obtain the client's vital signs.
Describe the blood transfusion procedure to the client.
Check for the type and number of units of blood to administer.
Initiate a peripheral IV line.: Check for the type and number of units of blood to
administer.
12. A nurse is caring for a client who has a leg cast and is returning to
demonstrate the proper use of crutches while climbing stairs. Identify the
sequence the client should follow when demonstrating crutch use.
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Shifts weight from the crutches to the unaffected leg
Places body weight on the crutches
Brings crutches and the affected leg up to the stair
Advances the unaffected leg onto the stair: Places body weight on the crutches
advances the unaffected leg onto the stair
shifts weight from crutches to the unaffected leg
Brings the crutches and the affected leg up to the stair
13. A nurse is teaching a group of newly licensed nurses about pain man-
agement for older adult clients. Which of the following statements by a newly
licensed nurse indicates understanding of the teaching?
"Older adult clients might require up to 6 grams of acetaminophen over 24
hours for effective pain control."
"Ibuprofen can cause gastrointestinal bleeding in older adult clients."
"Meperidine is the medication of choice for older adult clients experiencing
severe pain."
"Older adult clients taking oxycodone are at risk for diarrhea.": Ibuprofen can
cause gastrointestinal bleeding in older adult clients
14. A nurse is teaching a client who has a family history of colorectal cancer.
To help mitigate this risk, which of the following dietary alterations should the
nurse recommend?
Add full-fat yogurt to the diet.
Add cabbage to the diet.
Replace butter with coconut oil.
Replace shellfish with red meat.: Add cabbage to the diet
15. A nurse in an emergency department is caring for a client who has
full-thickness burn over 20% of their total body surface area. After ensuring a
patent airway and administering oxygen, which of the following items should
the nurse prepare to administer first?
IV fluids
Analgesia
Antibiotics
Tetanus toxoid: IV fluids
16. 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?
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1. A nurse is caring for a client who is receiving dialysis treatment.
Nurses' Notes
0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultat-
ed for bruit. Lung sounds clear upon auscultation; client denies shortness of
breath. No peripheral edema noted; capillary refill is less than 3 seconds; +2
bilateral pedal and radial pulses.
AVF access prepared and cannulated twice with no difficulty. Lines are taped
and secured; treatment is initiated.0600:
Client is reading a book. Access is visible, and lines are secure. Client reports
no discomfort or pain.0630:
Client reports feeling warm, nauseated, and lightheaded; appears restless and
slightly confused.
Vital Signs
0530:
Weight 88 kg (194 lb)
Temperature 37° C (98.6° F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure
Sitting - 148/90 mm Hg
Standing - 144/88 mm Hg
Oxygen saturation 98% on room air0600:
B: Place the client in Trendelenburg position
Administer a 0.9% sodium chloride 200 mL IV bolus
Apply oxygen at 2 L/min via nasal cannula
Notify the provider immediately
2. A nurse is caring for a client who is postoperative following abdominal
surgery.
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client is drowsy,
but arouses to verbal stimuli. Oriented x3, moves all extremities. Normal
sinus rhythm. Chest clear. Dressing to abdomen intact, small amount of
serosanguinous drainage noted and marked. No bowel sounds x 4 quadrants.
Indwelling urinary catheter in place, draining clear yellow urine. Lactated
Ringer's infusing at 100 mL/hr via IV catheter to right forearm.1200:
Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
intact, no further drainage noted. Urine output 15 mL since arrival from PACU.
Analgesic and antiemetic administered as prescribed.1230:
Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO2 96%.
Repositioned for comfort. Encouraged to turn, cough, and deep breathe.1300:
No additional urin: 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 scale of 0-10
3. A nurse is caring for a client who is receiving total parental nutrition (TPN). A
new bag is not available when the current infusion is nearly completed. Which
of the following actions should the nurse take?
Keep the line open with 0.9% sodium chloride until the new bag arrives.
Administer dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.: Administer dextrose 10%
in water until the new bag arrives.
4. A nurse is caring for a client who had a nephrostomy tube inserted 12 hr
ago. Which of the following findings indicates a potential complication?
The client's urinary output has increased.
The client reports back pain.
The client's urine color is red tinged.
The client's tube requires irrigation.: The client reports back pain
5. A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
Loosen the clothing around the client's neck.
Check the client's pupillary response.
Turn the client to the side.
Move furniture away from the client.: Turn the client to the side
6. 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?
Report of a night cough
Report of tinnitus
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
Report of excessive tearing
Report of increased salivation: Report of a night cough
7. 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.: Use a 30-mL syringe
8. A nurse is assessing a client who has Graves' disease. Which of the follow-
ing images should indicate to the nurse that the client has exophthalmos?: -
Bulging or protruding eyes
9. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which
of the following should indicate to the nurse that the client's condition is
improving?
Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
pH 7.28 (7.35 to 7.45)
Glucose 272 mg/dL (74 to 106 mg/dL)
HCO3- 14 mEq/L (21 to 28 mEq/L): Glucose 272 mg/dL
10. A nurse is caring for a client who has hypothyroidism. Which of the follow-
ing manifestations should the nurse expect?
Constipation
Insomnia
Tachycardia
Diaphoresis: Constiptation
11. A nurse is prepare to administer a blood transfusion to a client who has
anemia. Which of the following actions should the nurse take first?
Obtain the client's vital signs.
Describe the blood transfusion procedure to the client.
Check for the type and number of units of blood to administer.
Initiate a peripheral IV line.: Check for the type and number of units of blood to
administer.
12. A nurse is caring for a client who has a leg cast and is returning to
demonstrate the proper use of crutches while climbing stairs. Identify the
sequence the client should follow when demonstrating crutch use.
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
Shifts weight from the crutches to the unaffected leg
Places body weight on the crutches
Brings crutches and the affected leg up to the stair
Advances the unaffected leg onto the stair: Places body weight on the crutches
advances the unaffected leg onto the stair
shifts weight from crutches to the unaffected leg
Brings the crutches and the affected leg up to the stair
13. A nurse is teaching a group of newly licensed nurses about pain man-
agement for older adult clients. Which of the following statements by a newly
licensed nurse indicates understanding of the teaching?
"Older adult clients might require up to 6 grams of acetaminophen over 24
hours for effective pain control."
"Ibuprofen can cause gastrointestinal bleeding in older adult clients."
"Meperidine is the medication of choice for older adult clients experiencing
severe pain."
"Older adult clients taking oxycodone are at risk for diarrhea.": Ibuprofen can
cause gastrointestinal bleeding in older adult clients
14. A nurse is teaching a client who has a family history of colorectal cancer.
To help mitigate this risk, which of the following dietary alterations should the
nurse recommend?
Add full-fat yogurt to the diet.
Add cabbage to the diet.
Replace butter with coconut oil.
Replace shellfish with red meat.: Add cabbage to the diet
15. A nurse in an emergency department is caring for a client who has
full-thickness burn over 20% of their total body surface area. After ensuring a
patent airway and administering oxygen, which of the following items should
the nurse prepare to administer first?
IV fluids
Analgesia
Antibiotics
Tetanus toxoid: IV fluids
16. 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?
