ATI RN ADULT MEDICAL SURGICAL PROCTORED RETAKE EXAM 2019 WITH VERIFIED SOLUTIONS/A+ GRADE

A nurse is assessing for early signs of compartment syndrome for a client who has a
short-leg fiberglass cast. Which of the following findings should the nurse expect?
a. Capillary refill less than 2 seconds
b. Intense pain with movement
c. Bounding distal pulses
d. Erythema of the toes
2. A nurse is monitoring a client who is receiving 2 units of packed RBC’s. Which of the
following manifestations indicates a hemolytic transfusion reaction?
a. Bradycardia
b. Hypertension
c. Back pain
d. Chills
3. 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. Remove the wedge device when turning
b. Elevate the knees higher than the hips when sitting
c. Encourage the client to lean forward when attempting to stand
d. Place two bed pillows between the legs when in bed
4. A nurse is assessing a client who is perioperative 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. Povione-Iodine b. Latex
c. Anesthetics
d. Adhesive tape
● .
5. A nurse is teaching a client about the use of an incentive spirometer. Which of the
following instructions should the nurse include in the teaching?
a. Hold breaths about 3 to 5 seconds before exhaling
b. Position the mouthpiece 2.5cm (1 in.) from the mouth
c. Exhale slowly through pursed lips
d. Place hands on the upper abdomen during inhalation
.
6. A nurse is caring for a client who arrives at the emergency department and reports
vomiting and diarrhea for the past 3 days. The client’s serum potassium level is 2.8
extension, and hand-wall climbing) to prevent
mEq/L. Which of the following interventions should the nurse implement first?
a. Check the client’s hand grasps
b. Initiate cardiac monitoring for the client
c. Listen to the client’s bowel sounds
d. Administer an IV potassium drip
7. A nurse is preparing to administer peritoneal dialysis to a client. Which of the following
actions should the nurse take?
a. Hang the drainage bag below the client’s abdomen
b. Use clean technique to access the catheter
c. Chill the dialysate before administration
d. Place the client in high-fowlers position
8. A nurse is performing a cranial nerve assessment on a client following a head injury.
Which of the following findings should the nurse expect. If the client has impaired
function of the vestibulocochlear nerve (cranial nerve VIII)?
a. Loss of peripheral vision
b. Inability to smell
c. Deviation of the tongue from midline
d. Disequilibrium with movement
9. A nurse is planning care for a client who is 1 day postoperative following an open
cholecystectomy. Which of the following interventions should the nurse include in the
plan of care?
a. Place pillows under the client’s knees
b. Apply compression stockings to the lower extremities
c. Avoid use of anticoagulants
d. Discourage leg exercises while in bed
10. A nurse is caring for a male client who has an exacerbation of heart failure. Which of
the following prescriptions should the nurse expect to receive from the provider?
a. Atropine 1 mg IV bolus every 5 min up to 3 mg
b. Verapamil 80 mg PO TID
c. Adenosine 6 mg rapid IV bolus now
d. Furosemide 40 mg IV bolus every 6 hr
11. A nurse is providing discharge teaching to a client following a modified left radial
mastectomy with breast expander. Which of the following statements by the client
indicates an understanding of the teaching? ● Perform early arm and hand exercises
a. “I will perform strength-building arm exercises using 15-pound weight” (squeezing a rubber ball, elbow flexion and
lymphedema and to regain full range of
b. “I will keep my left arm flexed at the elbow as much as possible” motion.
c. “I should expect less than 25 mL of secretions per day in the drainage devices”
?
d. “I will have to wait 2 months before additional saline can be added to my breast expander”
12. A nurse is teaching a client about using a metered-dose inhaler. Which of the following
statements should the nurse indicate in the teaching
a. “Depress the canister after you inhale”
b. “Use peroxide to clean the mouthpiece of your inhaler”
c. “Do not shake your inhaler before use”
d. “Exhale fully before bringing the inhaler to your lips”
13. A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for
1 week. For which of the following findings should the nurse notify the provider?
a. Output 200 mL more than intake over the past 12 hr
b. Serum albumin level 3.9 g/dL
c. Calcium level 11.5 mg/dL
d. Fasting blood glucose level 105 mg/dL
14. A nurse is preparing to discharge a client who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following
prescriptions with the provider?
a. May operate a motor vehicle when no longer taking analgesics
b. Take tub baths instead of showers
c. May place a small pillow under the head when sleeping
d. Increase intake of fiber-rich foods
15. A nurse is setting up a sterile field before performing a dressing change on a client
who is postoperative. Which of the following actions should the nurse plan to take to
maintain the sterile field? (Select all that apply)
a. Opent the first flap of the sterile package toward the nurse’s body
b. Apply sterile gloves before opening the pack
c. Select a work surface at the nurse’s waist level
d. Place a surgical pack with a sterile drape on the work surface
e. Grasp 2.5 cm (1 in.) of the outer edge to open the surgical wrap
16. 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 actions is the nurse’s
priority?
a. Insert an indwelling urinary catheter
b. Obtain consent for surgery
c. Apply antiembolic stockings
d. Insert an NG tube
17. A nurse is assessing a client who has increased intracranial pressure. The nurse
should recognize which of the following is the first sign of deteriorating neurological
status?
a. Altered level of consciousness
b. Cheyne-stokes respirations
c. Decorticate posturing
d. Pupillary dilation
18. A nurse is performing skin cancer screening on a group of clients. Which of the
following findings should the nurse identify as an indication of melanoma?
a. Reddened lesion with dilated blood vessels
b. Flat lesion with irregular borders
c. Raised lesion with a rolled border
d. Scaly lesion with a crusted appearance
19. A nurse is caring for a client who has diabetes insipidus. Which of the following
medications should the nurse plan to administer?
a. Regular insulin
b. Lithium
c. Furosemide
d. Desmopressin