PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should
monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever
Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and causing
flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes
mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position.
D. Hold the client's finger in a dependent
position.
Rationale:
,PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
The nurse should clean the client's finger with an alcohol swab and prick the side of the finger,
not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could cause
false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month."
A. "It is common for one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's why
they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts." The
rest of the month breasts reamain tender due to hormone fluctuation.
,PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
"Self-Breast exams should be performed every month." For women in reproductive age usually
after a week when the period starts and at the same day of every month for women who have
attained menopause.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around
the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma."
C. "I will use a skin sealant before I apply the
bag."
Rationale:
An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out of
the body. It requires special care to keep the skin around it clean and prevent infection. A skin
sealant can protect the skin from irritation and help the bag stick better. The other statements are
incorrect because:
a) You may need to empty the bag more often than every 4 to 6 hours, depending on how much
waste you produce.
b) You should not use moisturizing soap to clean around the stoma, as it can leave a residue that
interferes with the bag's adhesion. You should use plain water or mild soap and rinse well.
d) You should cut the wafer opening to fit snugly around the stoma, not larger than it. A larger
opening can expose the skin to waste and cause irritation
, PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid
replacement. Which of the following interventions should the nurse contribute to the plan of
care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr.
B. Check for neck vein distention.
Rational:
Neck vein distention might be a sign of congestion of fluid in the vascular system, which can
occur when a person is receiving excessive IV fluids.
Offering oral fluids every 4 hours may be appropriate for a patient who is mildly dehydrated and
able to tolerate oral intake, but it is not recommended for a patient who is severely dehydrated
and receiving IV fluid replacement.
Limiting oral fluids prior to bedtime may be appropriate for a patient with nocturia, but it is not
relevant to the care of a dehydrated patient receiving IV fluid replacement.
Pulse pressure is the difference between the systolic and diastolic blood pressure readings. While
monitoring vital signs, including blood pressure, is important, pulse pressure may not be the
most relevant parameter to track in this context. Other vital signs like heart rate and blood
pressure could be more indicative of the client's overall condition
A nurse is caring for a young adult client who has testicular cancer and expresses concern about
their sexual function following an orchiectomy of the involved testicle. Which of the following
responses should the nurse make?
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should
monitor for which of the following adverse effects of the medication?
Nocturia
Increased saliva production
Flushing
Fever
Flushing
Rationale:
nitroglycerin is a vaso-dilator. When vaso-dilators too well, fluid start sipping out and causing
flushing
A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes
mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position.
D. Hold the client's finger in a dependent
position.
Rationale:
,PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
The nurse should clean the client's finger with an alcohol swab and prick the side of the finger,
not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could cause
false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month."
A. "It is common for one breast to be larger than
the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's why
they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts." The
rest of the month breasts reamain tender due to hormone fluctuation.
,PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
"Self-Breast exams should be performed every month." For women in reproductive age usually
after a week when the period starts and at the same day of every month for women who have
attained menopause.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following
statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around
the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma."
C. "I will use a skin sealant before I apply the
bag."
Rationale:
An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out of
the body. It requires special care to keep the skin around it clean and prevent infection. A skin
sealant can protect the skin from irritation and help the bag stick better. The other statements are
incorrect because:
a) You may need to empty the bag more often than every 4 to 6 hours, depending on how much
waste you produce.
b) You should not use moisturizing soap to clean around the stoma, as it can leave a residue that
interferes with the bag's adhesion. You should use plain water or mild soap and rinse well.
d) You should cut the wafer opening to fit snugly around the stoma, not larger than it. A larger
opening can expose the skin to waste and cause irritation
, PN ADULT MEDICAL SURGICAL 2024 ACTUAL EXAM /ATI PN ADULT
MEDICAL SURGICAL 2024 EXAM 230 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY GRADED A+
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid
replacement. Which of the following interventions should the nurse contribute to the plan of
care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr.
B. Check for neck vein distention.
Rational:
Neck vein distention might be a sign of congestion of fluid in the vascular system, which can
occur when a person is receiving excessive IV fluids.
Offering oral fluids every 4 hours may be appropriate for a patient who is mildly dehydrated and
able to tolerate oral intake, but it is not recommended for a patient who is severely dehydrated
and receiving IV fluid replacement.
Limiting oral fluids prior to bedtime may be appropriate for a patient with nocturia, but it is not
relevant to the care of a dehydrated patient receiving IV fluid replacement.
Pulse pressure is the difference between the systolic and diastolic blood pressure readings. While
monitoring vital signs, including blood pressure, is important, pulse pressure may not be the
most relevant parameter to track in this context. Other vital signs like heart rate and blood
pressure could be more indicative of the client's overall condition
A nurse is caring for a young adult client who has testicular cancer and expresses concern about
their sexual function following an orchiectomy of the involved testicle. Which of the following
responses should the nurse make?
