2023 ATI MED SURG PROCTORED EXAM TEST BANK 100
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES|ALREADY GRADED A+
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new
prescription for metformin. Which of the following statements by the client indicates an
understanding of the teaching?
B. “I should take this medication with a meal.”
RATIONALE: The client should take metformin with or immediately following meals
to improveabsorption and to minimize gastrointestinal distress
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not
available when the current infusion is nearly completed. Which of the following actions should
the nurse take?
C. Administer dextrose 10% in water until the new bag arrives
RATIONALE: TP solutions have a high concentration of dextrose. Therefore, if a
TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or
20% in water toavoid a precipitous drop in the client’s blood glucose level.
A nurse in a community clinic is caring for a client who reports an increase in the frequency of
migraine headaches. To help reduce the risk for migraine headaches, which of the following
foods should the nurse recommend the client to avoid?
B. Aged cheese
RATIONALE: Foods that contain tyramine, such as aged cheese and sausage, can
trigger migraineheadaches.
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion.
Which of the following prescribed medications should the nurse instruct the client to withhold
for 48 hr prior to cardioversion?
C. Digoxin
RATIONALE: There is an increased risk of ventricular arrhythmias developing in
patients taking digoxin during electrical cardioversion. Reduce dosage or withhold
therapy for 1 to 2days before elective cardioversion
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for ventricular
fibrillation after the synchronized countershock of cardioversion
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive
cough. Which of the following actions should the nurse take first?
D. Initiate airborne precautions
RATIONALE: This client is exhibiting manifestations of tuberculosis. The greatest risk in
this client situation is for other people in the facility to acquire an airborne disease from
this client.Therefore, the first action the nurse should take is to initiate airborne precautions
A nurse is caring for a client who has a stage III pressure injury. Which of the following findings
contributes to delayed wound healing?
D. Urine output 25 mL/hr
RATIONALE: Urinary output reflects fluid status. Inadequate urine output can indicate
dehydration,which can delay wound healing.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The
client appears anxious and restless, and the high-pressure alarm is sounding. Which of the
following actions should the nurse take first?
C. Instruct the client to allow the machine to breathe for them.
RATIONALE: When providing client care, the nurse should first use the least
restrictive intervention. Therefore, the first action the nurse should take is to provide
verbal instructions and emotional support to help the client relax and allow the
ventilator to work. Clients can exhibit anxiety and restlessness when trying to “fight the
ventilator.”
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose.
The client is experiencing excessive stools. Which of the following findings is an adverse effect
of this medication?
A. Hypokalemia
RATIONALE: Lactulose works by stimulating the production of excess stools to rid the
body of excessammonia. These excessive stools can result in hypokalemia and
dehydration.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for
the past 3 days. Which of the following findings should indicate to the nurse that the client is
experiencing fluid volume deficit?
A. Heart rate 110/min
RATIONALE: A client who has a 3-day history of vomiting and diarrhea is likely to
have fluid volumedeficit and an elevated heart rate.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the
following laboratory results to be below the expected reference range?
D. Calcium
RATIONALE: A client who has pancreatitis is expected to have decreased calcium and
magnesiumlevels due to fat necrosis.
A nurse is assessing a client who has Graves’ disease. Which of the following images should
indicate to the nurse that the client has exophthalmos?
D. The nurse should identify an outward protrusion of the eyes is exophthalmos a
common finding of graves disease.
RATIONALE: An overproduction of the thyroid hormone causes edema of the
extraocular muscle andincreases fatty tissue behind the eye, which results in the eyes
protruding outward.
Exophthalmos can cause the client to experience problems with vision, including
focusing on objects, as well as pressure on the optic nerve.
A nurse is caring for a client who was just admitted from the emergency department (ED).
Exhibit 1:
Nurses’ Notes
0945:
Client is experiencing a sickle cell crisis. Client states that they began experiencing pain
in the lower extremities 3 days ago and is now experiencing pain in the chest, rating it as
4 on scale of 0 to 10.
Oxygen at 3 L/min via nasal cannula in place.
Oral mucosa pink, no cyanosis.
Pulses palpable in all four extremities, no peripheral edema noted.
Respirations even and slightly labored; lung sounds with slight wheezing in left upper
lobe.
Abdomen soft and nontender, bowel sounds active in all four quadrants.
0.45% sodium chloride IV at 200 mL/hr infusing to left hand with no reports of pain or
swelling at the site.
1200:
Client is sitting up in high-Fowler’s position and appears anxious. Client reports shortness
of breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have
started coughing and are expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest
expansion noted. Neck veins flat. No peripheral edema observed.
Exhibit 2:
Vital Signs
0945:
Blood pressure 132/88 mm Hg
Respiratory rate 22/min
Temperature 38° C (100° F)
Heart rate 98/min
SaO2 95% on 3 L/min via nasal cannula
1200:
Blood pressure 136/90 mm Hg
Respiratory rate 32/min
pneumonia
acute chest syndrome
right-sided heart failure
fluid volume overload
pneumothorax
Temperature 38.7° C (101.6° F)
Heart rate 110/min
SaO2 90% on 3 L/min via nasal cannula
Drag words from the choices below to fill in each blank in the following sentence.
The client is most likely experiencing and .
Word Choices
Fluid volume overload is incorrect. While the client is experiencing an increased
respiratory rate and shortness of breath, fluid volume overload typically includes moist
crackles on auscultation, pitting edema in dependent areas, neck vein distension, and
hypertension.
Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at
risk for developing heart failure, the client does not have manifestations of right-sided
heart failure. Right-sided heart failure typically presents with signs of fluid volume
overload, which includes jugular vein distention, dependent edema, and blood pressure
alterations.
Acute chest syndrome is correct. The client is most likely experiencing acute chest
syndrome, which can be caused by respiratory infections and debris from sickled cells.
The client is displaying manifestations of acute chest syndrome, which include cough,
shortness of breath, wheezing, tachypnea, fever, and chest pain.
Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by
the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum,
and chest pain.
Pneumothorax is incorrect. While the client is experiencing increased respiratory
distress, a pneumothorax typically presents with reduced or absent breath sounds and
unequal chest expansion.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement?
D. Ensure that the client has a patent IV.
RATIONALE: The nurse should ensure the client has IV access in the event that the
client requiresmedication to stop seizure activity.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of
the following actions should the nurse take?
B. Check that one finger fits between the cast and the leg.