ATI RN MEDICAL SURGICAL WITH NGN 2024-2025 COMPLETE
180 QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES
Terms in this set (90)
A nurse is caring for a client who - Places body weight on the crutches
has a leg cast and is returning to - Advances the unaffected leg onto the stair
demonstrate on the proper use of - Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
crutches while climbing
stairs. Identify the sequence the
client
should follow when
demonstrating crutch use.
- Brings the crutches and the
affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the
crutches to the unaffected
leg
- Advances the unaffected leg
onto the stair
A nurse is caring for a client who - Constipation
has
hypothyroidism. Which of RATIONALE: A client who has hypothyroidism can experience
the following manifestations constipation due to the decrease in the client's metabolism,
should the nurse expect? resulting in slow motility of the GI tract. The
- Constipation
nurse should instruct the client to increase fiber and fluid
- Insomnia
intake to reduce the risk for constipation.
- Tachycardia
- Diaphoresis
,A nurse is assessing a client who - Alternate application of heat and cold to the affected joints
has a
diagnosis of rheumatoid RATIONALE: The nurse should instruct the client to alternate heat and
arthritis. Which of the following cold
nonpharmacological applications to decrease joint inflammation and pain. The
interventions should the nurse application of cold can relieve joint swelling and the application
suggest to the client to reduce of heat can decrease joint stiffness and pain.
pain?
- Increase intake of foods
containing calcium
- Alternate application of heat
and cold to the affected joints
- Keep the affected extremities
elevated
- Limit movement of the affected
joints
A nurse is caring for a client who - Slow the infusion rate
is
receiving a blood transfusion. The RATIONALE: Dyspnea, restlessness, and the onset of crackles during a
client becomes restless, blood
dyspneic, and has transfusion are manifestations of circulatory overload. The
crackles noted to the lung bases. nurse should slow or stop the infusion to improve the client's
Which of the following actions ability to breath, place the client in an upright position, and
should the nurse notify the provider. The provider might prescribe a diuretic to
anticipate taking? alleviate the fluid overload.
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower
extremities
A nurse in the emergency - "It's like a curtain closed over my eye."
department is assessing a client
who has a detached retina. RATIONALE: A retinal detachment is the separation of the
Which of the following should retina from the epithelium. It can occur because of trauma,
the nurse expect the client to cataract surgery, retinopathy, or uveitis. Clients who have
report? retinal detachment typically report the sensation of a curtain
- "It's like a curtain closed over being pulled over part of the visual field.
my eye."
- "This sharp pain in my eye
started 2 hours ago."
- "I've been having more and more
,difficulty seeing over the last few
weeks."
- "I seem to have more
problems seeing different
colors."
A nurse is teaching a client who has - Add cabbage to the diet
a family history of colorectal
cancer. To help RATIONALE: To help reduce the risk for colorectal cancer, the
mitigate this risk, which of the client should consume a diet that is high in fiber, low in fat,
following dietary alterations and low in refined carbohydrates. Brassica
vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
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
, - Instruct the client to splint the abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and
A nurse is caring for a client who deep breathe to reduce the risk for respiratory complications.
is The nurse should instruct the client to splint the incision while
postoperative following abdominal performing these actions to reduce the risk of complications
surgery.
to the
surgical incision.
A nurse is caring for a client
who is postoperative. Which of - Plan to ambulate the client as soon as possible
the following actions should the
nurse take? (Select all that RATIONALE: The nurse should plan to ambulate the client as
apply.) soon as possible to promote ventilation and decrease the risk
- Ask the client to rate their of thrombosis..
pain on a 0 to 10 pain scale
- Instruct the client to splint the - Report urinary output to the provider
abdomen with a pillow for
coughing RATIONALE: The client should produce at least 30 mL of urine
- Plan to ambulate the client per hour. Therefore, the nurse should report this finding to
as soon as possible the provider.
- Apply oxygen via a face mask
- Report urinary output to the - Ask the client to rate their pain on a 0 to 10 pain scale
provider
RATIONALE: 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 - The client's surgical site dressing has required changing
client who is twice in 2 hr due to drainage
postoperative following a
total hip arthroplasty. RATIONALE: Frequent dressing changing after surgery may
Which of the following indicate poor clotting and increased bleeding.
findings indicates that
the client is experiencing
a complication?
- The client reports that the
sequential compression
devices (SCDs) are
uncomfortable
180 QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES
Terms in this set (90)
A nurse is caring for a client who - Places body weight on the crutches
has a leg cast and is returning to - Advances the unaffected leg onto the stair
demonstrate on the proper use of - Shifts weight from the crutches to the unaffected leg
- Brings the crutches and the affected leg up to the stair
crutches while climbing
stairs. Identify the sequence the
client
should follow when
demonstrating crutch use.
- Brings the crutches and the
affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the
crutches to the unaffected
leg
- Advances the unaffected leg
onto the stair
A nurse is caring for a client who - Constipation
has
hypothyroidism. Which of RATIONALE: A client who has hypothyroidism can experience
the following manifestations constipation due to the decrease in the client's metabolism,
should the nurse expect? resulting in slow motility of the GI tract. The
- Constipation
nurse should instruct the client to increase fiber and fluid
- Insomnia
intake to reduce the risk for constipation.
- Tachycardia
- Diaphoresis
,A nurse is assessing a client who - Alternate application of heat and cold to the affected joints
has a
diagnosis of rheumatoid RATIONALE: The nurse should instruct the client to alternate heat and
arthritis. Which of the following cold
nonpharmacological applications to decrease joint inflammation and pain. The
interventions should the nurse application of cold can relieve joint swelling and the application
suggest to the client to reduce of heat can decrease joint stiffness and pain.
pain?
- Increase intake of foods
containing calcium
- Alternate application of heat
and cold to the affected joints
- Keep the affected extremities
elevated
- Limit movement of the affected
joints
A nurse is caring for a client who - Slow the infusion rate
is
receiving a blood transfusion. The RATIONALE: Dyspnea, restlessness, and the onset of crackles during a
client becomes restless, blood
dyspneic, and has transfusion are manifestations of circulatory overload. The
crackles noted to the lung bases. nurse should slow or stop the infusion to improve the client's
Which of the following actions ability to breath, place the client in an upright position, and
should the nurse notify the provider. The provider might prescribe a diuretic to
anticipate taking? alleviate the fluid overload.
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower
extremities
A nurse in the emergency - "It's like a curtain closed over my eye."
department is assessing a client
who has a detached retina. RATIONALE: A retinal detachment is the separation of the
Which of the following should retina from the epithelium. It can occur because of trauma,
the nurse expect the client to cataract surgery, retinopathy, or uveitis. Clients who have
report? retinal detachment typically report the sensation of a curtain
- "It's like a curtain closed over being pulled over part of the visual field.
my eye."
- "This sharp pain in my eye
started 2 hours ago."
- "I've been having more and more
,difficulty seeing over the last few
weeks."
- "I seem to have more
problems seeing different
colors."
A nurse is teaching a client who has - Add cabbage to the diet
a family history of colorectal
cancer. To help RATIONALE: To help reduce the risk for colorectal cancer, the
mitigate this risk, which of the client should consume a diet that is high in fiber, low in fat,
following dietary alterations and low in refined carbohydrates. Brassica
vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
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
, - Instruct the client to splint the abdomen with a pillow for coughing
RATIONALE: It is important for the client to turn, cough, and
A nurse is caring for a client who deep breathe to reduce the risk for respiratory complications.
is The nurse should instruct the client to splint the incision while
postoperative following abdominal performing these actions to reduce the risk of complications
surgery.
to the
surgical incision.
A nurse is caring for a client
who is postoperative. Which of - Plan to ambulate the client as soon as possible
the following actions should the
nurse take? (Select all that RATIONALE: The nurse should plan to ambulate the client as
apply.) soon as possible to promote ventilation and decrease the risk
- Ask the client to rate their of thrombosis..
pain on a 0 to 10 pain scale
- Instruct the client to splint the - Report urinary output to the provider
abdomen with a pillow for
coughing RATIONALE: The client should produce at least 30 mL of urine
- Plan to ambulate the client per hour. Therefore, the nurse should report this finding to
as soon as possible the provider.
- Apply oxygen via a face mask
- Report urinary output to the - Ask the client to rate their pain on a 0 to 10 pain scale
provider
RATIONALE: 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 - The client's surgical site dressing has required changing
client who is twice in 2 hr due to drainage
postoperative following a
total hip arthroplasty. RATIONALE: Frequent dressing changing after surgery may
Which of the following indicate poor clotting and increased bleeding.
findings indicates that
the client is experiencing
a complication?
- The client reports that the
sequential compression
devices (SCDs) are
uncomfortable
