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ATI MEDSURG PROCTORED 2 023
COMPLETE EXAM WITH 180
QUESTIONS AND 100% CORRECT
ANSWERS\ AGRADE
A nurse is caring for a client who has blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 4 oz grape juice. D. Report findings to the provider - ANSWER-C. Provide 4 oz grape juice. A nurse is preparing to administer a morning dose of aspart insulin (NovoLog) to a client who has type 1 diabetes mellitus. Which of the following is an appropriate action by the nurse? A. Check the client's blood glucose immediately after breakfast. B. Administer the insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time - ANSWER-B. Administer the insulin when breakfast arrives. A nurse is preparing to administer the morning doses of glargine (Lantus) insulin and regular (Humulin R) insulin to a client who has a blood glucose of 278 mg/dL. Which of the following is an appropriate nursing action? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes.
D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin. - ANSWER-C. Draw up and administer regular and glargine insulin in separate syringes. A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega-3 fatty acids in the diet. - ANSWER-A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. E. Include omega-3 fatty acids in the diet. A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes. - ANSWER-C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes. A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz of nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36oz of beer daily E. Getting a massage once a week - ANSWER-B. Eating popcorn at the movie theater D. Consuming 36oz of beer daily
and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypoglycemia. Which of the following data should the nurse report to the provider? A. Takes psyllium hydrophilic muccilloid (Metamucil) daily B. Drinks skim milk daily C. Takes metoprolol (Lopressor) daily D. Drinks grapefruit juice daily - ANSWER-C. Takes metoprolol (Lopressor) daily A nurse is presenting information to clients at a health fair on measures to reduce the risk of amputation. Which of the follow information should the nurse provide? (Select all that apply.) A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care. E. Advise clients to wait 2 hr after taking pain medication before driving. - ANSWER-A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care. A nurse is assessing an older adult client who has arteriosclerosis and is scheduled for a possible right lower extremity amputation. Which of the following are expected findings in the affected extremity? (Select all that apply.) A. Skin cool to touch from mid-calf to the toes B. Lower leg appears dusky when client is sitting C. Palpable pounding pedal pulse D. Lack of hair on lower leg E. Blackened areas on several toes - ANSWER-A. Skin cool to touch from mid- calf to the toes B. Lower leg appears dusky when client is sitting
D. Lack of hair on lower leg E. Blackened areas on several toes A nurse is caring for a client following a below-the-elbow amputation. Which of the following are appropriate actions by the nurse? (Select all that apply.) A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in a circular manner using gauze. E. Assess for feelings of body image changes. - ANSWER-A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. E. Assess for feelings of body image changes. A client who had an above-the-knee amputation reports having sharp, stabbing type of phantom pain. Which of the following is an appropriate action by the nurse? A. Facilitate counseling services. B. Encourage use of cold therapy. C. Question whether the pain is real. D. Administer an antiepileptic medication - ANSWER-D. Administer an antiepileptic medication A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following should the nurse include in the plan of care? A. Elevate the residual limb on a pillow. B. Position the client prone several times each day. C. Wrap the stump in a figure-eight pattern. D. Encourage sitting in a chair during the day. - ANSWER-B. Position the client prone several times each day. A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) A. Impulse control difficulty B. Left hemiplegia
C. Allow extra time for the client to answer. E. Give instructions one step at a time A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception - ANSWER-C. Inability to recognize familiar objects A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair - ANSWER-A. Prevention of further damage to the spinal cord A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110 mm Hg, with an apical heart rate of 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the client's urinary catheter for blockage. D. Administer antihypertensive medication. - ANSWER-B. Sit the client upright in bed. A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise - ANSWER-D. Respiratory compromise
A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants - ANSWER-D. Muscle relaxants A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter - ANSWER-A. Condom catheter A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods. - ANSWER-A. Provide assistance with ambulation. B. Monitor oxygen saturation. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods. A nurse is teaching a client who has a new prescription for ferrous sulfate (Feosol). Which of the following should be included in the teaching? A. Stools will be dark red in color. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days - ANSWER-C. Foods high in vitamin C will promote absorption.
A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure to the client. C. Obtain ABGs from the client. D. Administer benzocaine spray to the client - ANSWER-A. Position the client in an upright position, leaning over the bedside table. A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (Select all that apply.) A. Nail polish B. Inadequate peripheral circulation C. Hyperthermia D. Increased Hgb level E. Edema - ANSWER-. Nail polish B. Inadequate peripheral circulation E. Edema A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms - ANSWER-D. Bronchospasms A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit - ANSWER-A. Oxygen equipment C. Pulse oximeter D. Sterile dressing
A nurse is caring for a client following a thoracentesis. Which of the following clinical manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site - ANSWER-A. Dyspnea C. Fever D. Hypotension A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing - ANSWER-A. Oxygen B. Sterile water C. Enclosed hemostat clamps E. Occlusive dressing A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal. B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess the client's respiratory status. - ANSWER-B. Apply sterile gauze to the insertion site. A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber
A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure - ANSWER-B. Pale skin E. Elevated blood pressure A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr. - ANSWER-D. Assess breath sounds every 1 to 2 hr. A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask - ANSWER-B. Venturi mask A nurse is planning care for a client who is receving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continous positive aiway pressure D. Pressure support ventilation
E. Independent lung ventilation - ANSWER-B. Synchronized intermittent mandatory ventilation C. Continous positive airway pressure D. Pressure support ventilation Which of the following clients have an increased risk for developing pneumonia? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis - ANSWER-A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis A nurse in a clinic is caring for a client who was brought to the clinic by her partner. The partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following is the priority nursing action? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccination. - ANSWER-A. Obtain baseline vital signs and oxygen saturation. A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, BP 130/76, heart rate 100/min, and SaO 91% on room air. Using a scale of 1 to 4, with 1 being the highest priority, prioritize the following nursing interventions. A. Administer antibiotics as prescribed. B. Administer oxygen therapy. C. Perform a sputum culture.
medications should the nurse expect to administer? A. Antibiotic B. Beta-blocker C. Antiviral D. Beta2 agonist - ANSWER-D. Beta2 agonist A nurse is completing discharge teaching with a client who has a new prescription for prednisone (Deltasone) for asthma. Which of the following client statements indicates a need for further teaching? A. "I will drink plenty of fluids while taking this medication." B. "I will tell the doctor if I have black, tarry stools." C. "I will take my medication on an empty stomach." D. "I will monitor my mouth for canker sores." - ANSWER-C. "I will take my medication on an empty stomach." A nurse is assessing a client with asthma. Which of the following is a risk factor associated with this disease? A. Gender B. Environmental allergies C. Alcohol use D. Race - ANSWER-B. Environmental allergies A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following statements by the client indicates the teaching was effective? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms." - ANSWER-B. "I take this medication to prevent asthma attacks." A nurse is providing discharge teaching to a client who has COPD and has a new prescription for albuterol (Proventil). Which of the following statements made by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response."
C. "I can have an increase in my heart rate while taking this medication." D. "I can have mouth sores while taking this medication." - ANSWER-C. "I can have an increase in my heart rate while taking this medication." A nurse is preparing to administer a new prescription prednisone (Deltasone) to a client who has COPD. Which of the following should the nurse monitor for? (Select all that apply.) A. Monitor the client or hypokalemia. B. Monitor the client for tachycardia. C. Observe the client for fluid retention. D. Monitor the client for nausea. E. Advise the client to report black, tarry stools. - ANSWER-A. Monitor the client or hypokalemia. C. Observe the client for fluid retention. E. Advise the client to report black, tarry stools. A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling." - ANSWER-D. "I will take in a deep breath and hold it before exhaling." A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you so you will not need to get out." - ANSWER-A. "There are portable oxygen delivery systems that you can take with you."
multimedication regimen. Which of the following instructions should the nurse give the client related to the medication ethambutol (Myambutol)? A. "Your urine may turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily." - ANSWER-C. "Watch for any changes in vision." A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. Which of the following is an appropriate statement by the nurse about this medication? A. "You may notice yellowing of your skin." B. "You may experience pain in your joints." C. "You may notice tingling of your hands." D. "You may experience a loss of appetite." - ANSWER-C. "You may notice tingling of your hands." A nurse is providing information to a group of clients at a local community center about tuberculosis. Which of the following clinical manifestations should be included in the teaching? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum - ANSWER-A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation - ANSWER-A. A client who has a BMI of 30
C. A client who has a fractured femur E. A client who has chronic atrial fibrillation A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/ mm Hg. Which of the following actions is the priority action at this time? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan. - ANSWER-C. Administer oxygen therapy. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath." - ANSWER-B. "I take antacids several times a day." A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia - ANSWER-B. Pleural friction rub D. Petechiae E. Tachycardia A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago
