MedSurge ATI Exam
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1. A nurse is caring for a client who is receiving dialysis Place the client in Trende-
treatment. lenburg position
Nurses' Notes Administer a 0.9% sodium
0530: chloride 200 mL IV bolus
Client is awake and alert. Apply oxygen at 2 L/min
Arteriovenous fistula (AVF) to right forearm with thrill via nasal cannula
palpated and auscultated for bruit. Lung sounds clear Notify the provider imme-
upon auscultation; client denies shortness of breath. diately
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 light-
headed; 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
2. A nurse is caring for a client who is postoperative Instruct the client to splint
following abdominal surgery. the abdomen with a pillow
Nurses' Notes for coughing
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1100: Plan to ambulate the client
Client received from PACU; initial vital signs record- as soon as possible
ed. Client is drowsy, but arouses to verbal stim- Report urinary output to
uli. Oriented x3, moves all extremities. Normal si- the provider
nus rhythm. Chest clear. Dressing to abdomen intact, Ask the client to rate their
small amount of serosanguinous drainage noted and pain on a scale of 0-10
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 intact, no further
drainage noted. Urine output 15 mL since arrival from
PACU. Analgesic and antiemetic administered as pre-
scribed.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
3. A nurse is caring for a client who is receiving total Administer dextrose 10%
parental nutrition (TPN). A new bag is not available in water until the new bag
when the current infusion is nearly completed. Which arrives.
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.
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4. A nurse is caring for a client who had a nephrostomy The client reports back
tube inserted 12 hr ago. Which of the following find- pain
ings 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.
5. A nurse is caring for a client who is having a seizure. Turn the client to the side
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.
6. A nurse in a provider's office is assessing a client who Report of a night cough
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
Report of excessive tearing
Report of increased salivation
7. A nurse is planning to irrigate and dress a clean, gran- Use a 30-mL syringe
ulating wound for a client who has a pressure injury.
Which of the following actions should the nurse take?
, MedSurge ATI Exam
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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.
8. A nurse is assessing a client who has Graves' disease. Bulging or protruding
Which of the following images should indicate to the eyes
nurse that the client has exophthalmos?
9. A nurse is caring for a client who has diabetic ketoaci- Glucose 272 mg/dL
dosis (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)
10. A nurse is caring for a client who has hypothyroidism. Constiptation
Which of the following manifestations should the
nurse expect?
Constipation
Insomnia
Tachycardia
Diaphoresis
11. A nurse is prepare to administer a blood transfusion Check for the type and
to a client who has anemia. Which of the following number of units of blood
actions should the nurse take first? to administer.
Obtain the client's vital signs.
Describe the blood transfusion procedure to the
Study online at https://quizlet.com/_ewvpbz
1. A nurse is caring for a client who is receiving dialysis Place the client in Trende-
treatment. lenburg position
Nurses' Notes Administer a 0.9% sodium
0530: chloride 200 mL IV bolus
Client is awake and alert. Apply oxygen at 2 L/min
Arteriovenous fistula (AVF) to right forearm with thrill via nasal cannula
palpated and auscultated for bruit. Lung sounds clear Notify the provider imme-
upon auscultation; client denies shortness of breath. diately
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 light-
headed; 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
2. A nurse is caring for a client who is postoperative Instruct the client to splint
following abdominal surgery. the abdomen with a pillow
Nurses' Notes for coughing
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
1100: Plan to ambulate the client
Client received from PACU; initial vital signs record- as soon as possible
ed. Client is drowsy, but arouses to verbal stim- Report urinary output to
uli. Oriented x3, moves all extremities. Normal si- the provider
nus rhythm. Chest clear. Dressing to abdomen intact, Ask the client to rate their
small amount of serosanguinous drainage noted and pain on a scale of 0-10
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 intact, no further
drainage noted. Urine output 15 mL since arrival from
PACU. Analgesic and antiemetic administered as pre-
scribed.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
3. A nurse is caring for a client who is receiving total Administer dextrose 10%
parental nutrition (TPN). A new bag is not available in water until the new bag
when the current infusion is nearly completed. Which arrives.
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.
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
4. A nurse is caring for a client who had a nephrostomy The client reports back
tube inserted 12 hr ago. Which of the following find- pain
ings 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.
5. A nurse is caring for a client who is having a seizure. Turn the client to the side
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.
6. A nurse in a provider's office is assessing a client who Report of a night cough
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
Report of excessive tearing
Report of increased salivation
7. A nurse is planning to irrigate and dress a clean, gran- Use a 30-mL syringe
ulating wound for a client who has a pressure injury.
Which of the following actions should the nurse take?
, MedSurge ATI Exam
Study online at https://quizlet.com/_ewvpbz
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.
8. A nurse is assessing a client who has Graves' disease. Bulging or protruding
Which of the following images should indicate to the eyes
nurse that the client has exophthalmos?
9. A nurse is caring for a client who has diabetic ketoaci- Glucose 272 mg/dL
dosis (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)
10. A nurse is caring for a client who has hypothyroidism. Constiptation
Which of the following manifestations should the
nurse expect?
Constipation
Insomnia
Tachycardia
Diaphoresis
11. A nurse is prepare to administer a blood transfusion Check for the type and
to a client who has anemia. Which of the following number of units of blood
actions should the nurse take first? to administer.
Obtain the client's vital signs.
Describe the blood transfusion procedure to the
