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Emory University Nell Hodgson woodruff School of
Nursing (Atalanta, GA)ATI Medical-Surgical Proctored
Exam 202 5 : Comprehensive Study Guide with Expert-
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1. A nurse is planning to teach a client whose provider has prescribed a low-purine diet. The nurse should plan to instruct the client that they can include which of the following foods in their diet? (Select all that apply) a) Sardines b) Nuts (Correct Answer) c) Apricots (Correct Answer) d) Liver e) Scallops Rationale: Sardines, liver, and scallops are high in purines and should be avoided by clients with conditions like gout. Nuts and apricots are low-purine foods and are safe to consume. 2. A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take? a) Place pillows under the client's knee b) Gently massage the area around the client’s incision c) Apply an ice pack to the client’s knee (Correct Answer) d) Perform range-of-motion exercises to the client’s knee Rationale: Applying ice reduces inflammation and provides pain relief. Placing pillows under the knee could promote contractures, and massaging near the incision may cause discomfort. 3. A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include? a) Limit visitation time for client's children to 40 minutes per day b) Clean the equipment in the client's room once per week c) Provide a diet of fresh fruits and vegetables for the client
d) Apply new gloves when alternating between wound care sites (Correct Answer: d) Rationale: Infection control is critical for burn patients. Changing gloves between wound sites prevents cross-contamination and reduces the risk of infection. 4. A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy." Which of the following responses should the nurse make? a) "I have never heard of any holistic treatment that is effective." b) "You should ask your provider about your plan." c) "The best way to treat your cancer is chemotherapy." d) "Tell me what you know about chemotherapy." (Correct Answer: d) Rationale: This response encourages open communication and assesses the client's knowledge, allowing the nurse to provide appropriate education and support.
5. A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches. Which of the following client statements indicates that the client is adapting to their role change? a) "I will need to have my partner take over shopping for groceries and cooking the meals for us." (Correct Answer) b) "It’s going to be difficult to tell my parents I can't take them to their appointments anymore." c) "I feel bad that I have to ask my partner to keep the house clean." d) "These crutches will make it impossible to care for my child." Rationale: This statement demonstrates problem-solving and adaptation to the temporary limitation by delegating tasks. Other statements reflect distress or inability to cope effectively. 6. A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances? a) Adhesive tape b) Latex (Correct Answer) c) Anesthetics d) Povidone-iodine
b) hypertension c) oral contraceptive use d) cirrhosis - - correct ans- - c) oral contraceptive use A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? a) Remove soiled linens from the room after each change b) Give the dosimeter badge to the oncoming nurse at the end of the shift c) Apply a second pair of gloves before touching the client's implant if it dislodges d) Limit family member visits to 30 min per day - - correct ans- - d) Limit family member visits to 30 min per day A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? a) Generalized abdominal pain b) Cloudy effluent c) Increased heart rate d) Fever - - correct ans- - d) Fever A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications? a) Pantoprazole b) Acetaminophen c) Furosemide d) Diphenhydramine - - correct ans- - c) Furosemide
A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer. Which of the following actions should the nurse plan to take? a) Provide ketorolac for abdominal pain b) Administer nitroprusside IV based on the client's weight c) Insert a large bore nasogastric tube d) Ensure that the client has a 22- gauge iv line in place - - correct ans- - c) Insert a large bore nasogastric tube A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? a) Instruct client to avoid eating raw fruit b) Move the client to a negative pressure room c) Use contact isolation while providing care d) Apply pressure to venipuncture sites for 10 min - - correct ans- - a) Instruct client to avoid eating raw fruit A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia and tachypnea. Which of the following positions should the nurse place the client? a) Reverse Trendelenburg b) Feet elevated c) Side lying d) High - fowler's - - correct ans- - Feet elevated A nurse is caring for a client who weighs 190 lb and is receiving Total parenteral Nutrition. If the RDA Protein is 0.8g/kg of body weight, how many grams of protein should the client receive daily (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero) - - correct ans- - Answer: 69 grams
A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect? a) Progressively longer PR durations b) undetectable p waves c) absent PR intervals with ventricular rate of 40 to 60 / minutes d) Sawtooth pattern with atrial rate of 252 400 / minutes - - correct ans- - d) Sawtooth pattern with atrial rate of 252 400 / minutes A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take which of the following actions? a) Administer a stool softener following the procedure b) ask the client to empty his bladder prior to the procedure c) instruct the client to take deep breaths and hold them during the procedure d) assist the client into the left lateral position during the procedure - - correct ans- - b) ask the client to empty his bladder prior to the procedure A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse? a) Pulse pressure changes from 30 to 20 mmhg b) bilateral pupil diameter changes from 4 to 2 mm c) WBC count changes from 9,000 to 16,000 / mm 3 d) Glasgow Coma Scale score changes from 14 to 9 - - correct ans- - d) Glasgow Coma Scale score changes from 14 to 9 A nurse is administering furosemide 80 mg PO twice-daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? a) Respiratory rate of 24 / min b) adventitious breath sounds c) weight loss of 1.8 kg (4 lb) in the past 24 hours
d) elevation in blood pressure - - correct ans- - c) weight loss of 1.8 kg (4 lb) in the past 24 hours A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contradiction for receiving the medication? a) Creatinine 0.8 mg / DL b) sodium 136 meq / L c) potassium 3.2 meq / L d) bzun 18 mg / DL - - correct ans- - c) potassium 3.2 meq / L A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take? a) Place the dosimeter film badge on a client's door b) wear a lead apron when providing client care c) leave the door to the clients room open d) allow visitors to hold the clients hand - - correct ans- - b) wear a lead apron when providing client care A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months which of the following results should the nurse monitor to determine long-term glycemic control? a) Glycosylated hemoglobin level b) fasting blood glucose level c) oral glucose tolerance test results d) post-prandial blood glucose level - - correct ans- - a) Glycosylated hemoglobin level A nurse is providing preoperative teaching for a client who is having left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching? a) You should plan to remain in bed for 18 hours after the procedure
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? a) I should expect to take my medication for three weeks b) I should apply antibiotic ointment to the lesions c) I should expect my lesions to resolve in 6 weeks d) I should use natural skin condoms during sexual intercourse - - correct ans- - C) lesions resolve in 6 weeks A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg / DL which of the following action is the nurse's priority? a) Insert an NG Tube b) obtain consent for surgery c) apply anti embolic stockings d) insert an indwelling urinary catheter - - correct ans- - a) Insert an NG Tube A nurse is preparing to administer two units of packed rbc's to a client. Which of the following actions should the nurse take? a) Transfuse each unit of blood over five hours b) change the IV tubing after each unit of blood is transfused c) administer the blood through a 22 gauge intravenous catheter d) Prime the tubing with 0.9% sodium chloride - - correct ans- - d) Prime the tubing with 0.9% sodium chloride A nurse is caring for a client who has chronic renal failure. The client displays the following ABG results: pH: 7.24 paCO2: 44 mm Hg, paO2 : 84 mmHg, HCO3 : 18 meq/ L base excess - 2 and O2 saturation 95% The nurse should include that the client has which of the following acid-base balances? a) Metabolic alkalosis b) respiratory acidosis c) respiratory alkalosis d) metabolic acidosis - - correct ans- - Metabolic acidosis
A nurse in a provider's office is teaching a client about the self management of GERD which of the following instruction should the nurse include? a) Lie down 30 minutes after each meal b) sleep with the head of your bed elevated 6 inches c) increase your caloric intake by 250 calories per day d) Eat A light meal 1 hour before bedtime - - correct ans- - b) sleep with the head of your bed elevated 6 inches A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? a) Cool, clammy skin b) kussmaul respirations c) acetone breath d) increased urine output - - correct ans- - a) Cool, clammy skin A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when finding the clients meals? a) Offer hot beverages with meals b) offer a snack prior to radiation therapy c) offer highly seasoned Foods d) offer frequent High carbohydrate meals - - correct ans- - d) offer frequent High carbohydrate meals A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the information diagnosis which of the following clients requires a private room? a) A client reports having fever, night sweats, and call for 2 days b) an older adult client who was admitted with aspiration pneumonia
A nurse is planning care for a client who has status epilepticus. Which of the following interventions is the nurses priority to include? a) Administer phenytoin IV bolus to the client b) provide the client oxygen at 6 L / min using a nasal cannula c) turn the client to the lateral position during seizure activity d) administer diazepam intravenously to the client - - correct ans- - c) turn the client to the lateral position during seizure activity A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? a) Elevate the knees higher than the hips when sitting b) remove the wedge device when turning c) encourage the client to lean forward when attempting to stand d) place two bed pillows between the legs when in bed - - correct ans- - d) place two bed pillows between the legs when in bed A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane infusion is almost complete and the new solution is not available which of the following actions should the nurse take? a) Infuse dextrose 10% in water b) decrease that tpn infusion rate c) disconnect and flush the IV access line d) administer lactated ringers through the peripheral IV site - - correct ans- - a) Infuse dextrose 10% in water A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? a) Adjust the clamps on the fixator frame b) maintain the affected extremity in a dependent position c) palpate the dorsalis pedis pulse
d) rap sterile gauze on the sharp point of the pins - - correct ans- - c) palpate the dorsalis pedis pulse A nurse is caring for a client in the emergency department who experienced a full thickness burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse expect? a) Hypotension b) Bradycardia c) decrease respiratory rate d) urinary diuresis - - correct ans- - a) Hypotension A nurse is planning care for an older adult client who has Meniere's disease. Which of the following interventions should the nurse include in the plan? a) Perform range of motion exercises to the client's neck every 4 hours b) limited clients fluid intake to 1500 ml / day c) administer aspirin if the client reports a headache d) encourage the client to change position slowly - - correct ans- - d) encourage the client to change position slowly A nurse is assessing a client who has a diagnosis on colon cancer which of the following should the nurse expect? a) Statorrhea b) Elevated hemoglobin c) Hematochezia d) Weight gain - - correct ans- - c) Hematochezia A nurse is assessing a client admitted with peripheral vascular disease,. Which of the following findings indicates a venous vascular disorder?
A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? a) " use raised toilet seat to maintain your hips above the knees" b) " twist at the waist when standing from a seated position" c) "move your stronger leg first when using a walker" d) " apply a heating pad to the operative hip to decrease pain" - - correct ans- - a) " use raised toilet seat to maintain your hips above the knees" A nurse finds a client in bed, unresponsive and breathing. Which of the following action should the nurse take first? a) Establish IV access b) Apply blood pressure cuff c) Palpate for the client's carotid pulse d) Initiate cardiac monitoring for the client - - correct ans- - c) Palpate for the client's carotid pulse A nurse is caring who is experiencing a hypertensive crisis. Which of the following actions should the nurse take? a) Initiate IV dopamine infusion b) Perform neurological assessments c) Place the client supine d) Begin an IV bolus of lacted ringer's - - correct ans- - b) Perform neurological assessments A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should instruct the client to obtain which of the following supplies? a) Sterile lancets b) Compression stockings c) Hand mirror d) Toenail clippers - - correct ans- - A) sterile lancets A nurse is completing discharge teaching who has a peripherally inserted central catheter ( PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching?
a) Do not elevate the arm above the level of the heart b) Change the catheter dressing daily c) Use 10- mL syringe to flush line d) Clean the insertion site using 20- mL of hydrogen peroxide - - correct ans- - a) Do not elevate the arm above the level of the heart A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lbs. the amount available is 0.4 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth) - - correct ans- - 2.5ML A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? a) Opioid analgesic b) Anticonvulsant c) anti thrombotic d) diuretic - - correct ans- - c) anti thrombotic A nurse is caring for a client who has a new colostomy the nurse notes that the client appears withdrawn and looks away during ostomy care. Which of the following actions should the nurse take? a) Ask the client how they feel about the stoma b) make a referral for the client to see an ostomy nurse c) include the clients partner in stoma care education d) educate the client about expected stoma appearance - - correct ans- - a) Ask the client how they feel about the stoma
d) vegetable soup - - correct ans- - c) vanilla pudding A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? a) Half cup non-fat yogurt b) two tablespoons of peanut butter c) 1 Cup white rice d) one medium baked potato with skin - - correct ans- - c) 1 Cup white rice A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax? a) Diminished breath sounds b) Itching over the incision c) Distended neck veins d) Irregular heart rate - - correct ans- - a) Diminished breath sounds A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take when performing a close intermittent irrigation? a) Use a 3ml syringe to perform the catheter irrigation b) Clamp the catheter above the specimen port c) Place the client in Trendelenburg position d) Inject the irrigation solution slowly into the catheter - - correct ans- - d) Inject the irrigation solution slowly into the catheter A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? a) I will need to take my clothes to the dry cleaners to sterilize them
b) I will wipe up areas soiled with body fluids with alcohol and immediately disposed of the trash (should be cleaned with bleach not alcohol) c) I will be sure to wear gloves and wash my hands when I change my cat's litter box d) I will increase the amount of fresh fruits and vegetables I consume - - correct ans- - c) I will be sure to wear gloves and wash my hands when I change my cat's litter box A nurse is caring for a client who is post-operative following an endoscopy with moderate (conscious) Sedation. Which of the following assessment findings is the nurse's priority? a) Level of pain b) Gag reflex c) Warmth of extremities d) Temperature - - correct ans- - b) Gag reflex Nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse's priority? a) Obtain a history to determine recent injuries b) Obtain a broad-spectrum antibiotic for Rapid Administration c) Obtain a WBC count with differential d) Obtain a blood specimen for culture and sensitivity testing - - correct ans- - d) Obtain a blood specimen for culture and sensitivity testing A nurse is caring for a client who has just undergone a total laryngectomy. Which of the following findings is the nurse's priority for immediate intervention? a) Blood-tinged secretions b) Tachypnea c) Fever d) IV infiltration - - correct ans- - b) Tachypnea
