RN 2019 ADULT MEDICAL SURGICAL ATI PROCTORED
TEST BANK 300 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
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A nurse is preparing to administer a blood transfusion to a client who has anemia.
Which of the following actions should the nurse take first?
Obtain the client’s vital signs.
Describe the blood transfusion procedure to the client.
Check for the type and number of units of blood to administer.
Initiate a peripheral IV line. – ANSWER- Check for the type and number of units
of blood to administer
A nurse is reviewing the laboratory results of a client who has aplastic anemia.
Which of the following findings indicates a potential complication?
RBC count 5.2 million/mm3
WBC count 2,000/mm3
Platelets 380,000/mm3
Potassium 4 mEq/L – ANSWER- WBC count 2,000
A nurse is providing discharge teaching to a client who is postoperative following
a modified radical mastectomy. Which of the following instructions should the
nurse include?
Flex the affected arm when ambulating.
Numbness can occur along the inside of the affected arm.
Begin active range-of-motion exercises 1 day after surgery.
Dress in clothing that fits snugly. – ANSWER- Numbness can occur along the
inside of the affected arm
A nurse is preparing to present a program about prevention of atherosclerosis at a
health fair. Which of the following recommendations should the nurse plan to
include? (Select all that apply.)
Follow a smoking cessation program.
Maintain an appropriate weight.
Eat a low-fat diet.
Increase fluid intake.
Decrease intake of complex carbohydrates. – ANSWER- Follow a smoking
cessation program
Maintain an appropriate weight
Eat a low-fat diet
A nurse is caring for a client who has homonymous hemianopsia as a result of a
stroke. To reduce the risk of falls when ambulating, the nurse should provide
which of the following instructions to the client?
“Wear an eye patch over one eye.”
“Make sure to have a staff member walk on your stronger side.”
“Scan the environment by turning your head from side to side.”
“Make sure to look at your feet while walking.” – ANSWER- Scan the environment
by turning your head from side to side.”
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage
system. Which of the following findings is an indication of lung re-expansion?
The chest tube is draining serosanguineous fluid at 65 mL/hr
The client tolerates gentle milking of the tubing.
Bubbling in the water seal chamber has ceased.
There is tidaling in the water seal chamber. – ANSWER- Bubbling in the water seal
chamber has ceased.
A nurse is providing discharge teaching to a client who is to self-administer
heparin subcutaneously. Which of the following statements by the client indicates
an understanding of the teaching?
“I can expect to have blood in my urine during the first week of injections.”
“I will floss my teeth after each meal.”
“I will gently massage the site after I inject my medication.”
“I will use an electric razor to shave.” – ANSWER- I will use an electric razor to
shave
A nurse is providing follow-up care for a client who sustained a compound fracture
3 weeks ago. The nurse should recognize that an unexpected finding for which of
the following laboratory values is a manifestation of osteomyelitis and should be
reported to the provider?
Sedimentation rate
Hematocrit
Calcium
Acid phosphatase – ANSWER- Sedimentation rate
A nurse is performing a preoperative assessment for a client. The nurse should
identify that an allergy to which of the following foods can indicate a latex allergy?
Shellfish
Peanuts
Avocados
Eggs – ANSWER- Avocados
A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client’s condition is improving?
Potassium 3.5 mEq/L
glucose 272
pH 7.28
HCO3 14 – ANSWER- Glucose 272
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the
following should the nurse plan to administer?
240 mL (8 oz) of orange juice
1 ampule of 50% dextrose IV bolus
NPH insulin 60 units subcutaneous
Regular insulin 20 units IV bolus – ANSWER- Regular insulin 20 units IV
RN 2019 ADULT MEDICAL SURGICAL FORM A AND FORM B
ACTUAL EXAMS EACH FORM CONTAINS 100 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
|ALREADY GRADED A+||BRAND NEW!!
FORM A
A nurse is providing discharge instructions to a client who has laryngeal cancer
and is receiving radiation therapy. Which of the following statements by the client
indicates an understanding of the teaching? – ANSWER- “I will avoid direct
exposure to the sun.”
A nurse is admitting a client who has active tuberculosis. Which of the following
types of transmission precautions should the nurse initiate? – ANSWER- Airborne
tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is reviewing the medical record of a client who has osteomyelitis and a
prescription for gentamicin. Which of the following findings from the client’s
medical record should indicate to the nurse the need to withhold the medication
and notify the provider? (Click on the “Exhibit” button for additional information
about the client. There are three tabs that contain separate categories of data.) –
ANSWER- Serum creatinine
A nurse is providing teaching to a client who is perimenopausal and has a
prescription for hormone replacement therapy. For which of the following adverse
effects should the nurse instruct the client to notify the provider? (Select all that
apply.) – ANSWER- Calf pain
Numbness in the arms
Intense headache
A nurse is planning discharge teaching for a client who has an external fixation
device for a fracture of the lower extremity. Which of the following instructions
should the nurse include in the plan of care? – ANSWER- Use crutches with rubber
tips.
A nurse is teaching a group of newly licensed nurses about pain management for
older adult clients. Which of the following statements by a newly licensed nurse
indicates an understanding of the teaching? – ANSWER- Ibuprofen can cause
gastrointestinal bleeding in older adult clients.
A nurse is caring for a client who has a cervical spinal cord injury sustained 1
month ago. Which of the following manifestations indicates that the client is
experiencing autonomic dysreflexia (AD)? – ANSWER- Heart rate 52/min
will exhibit multiple manifestations, including bradycardia, severe headache, and
flushing.
A nurse is assessing a client who has advanced lung cancer and is receiving
palliative care. The client has just undergone thoracentesis. The nurse should
expect a reduction in which of the following common manifestations of advanced
cancer? – ANSWER- Dyspnea
Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and
thus ease the client’s breathing and improve comfort.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make? –
ANSWER- “Ginkgo biloba can cause an increased risk for bleeding.”
A nurse on a medical-surgical unit is reviewing the medical record of an older
adult client who is receiving IV fluid therapy. Which of the following client
information should indicate to the nurse that the client requires re-evaluation of the
IV therapy prescription? (Click on the “Exhibit” button for additional information
about the client. There are three tabs that contain separate categories of data.)
EXHIBIT – ANSWER- BUN
A nurse is receiving report on a client who is postoperative following an open
repair of Zenker’s diverticulum. The nurse should anticipate the surgical incision to
be in which of the following locations? (You will find hot spots to select in the
artwork below. Select only the hot spot that corresponds to your answer.) –
ANSWER- Neck
Zenker’s diverticulum, or pharyngeal pouch, is a herniation of the esophagus
occurring through the cricopharyngeal muscle in the midline of the neck. Repair of
the diverticulum is accomplished through an open incision in the client’s neck.
A nurse is obtaining a medication history from a client who is scheduled to
undergo cataract surgery. The nurse should recognize that which of the following
client medications is a contraindication for the surgery and notify the provider? –
ANSWER- Warfarin
A nurse is assessing a client who has peripheral arterial disease. Which of the
following findings should the nurse expect? – ANSWER- Hair loss on the lower
legs
a result of impaired arterial circulation affecting follicular growth.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? – ANSWER- Change position every hour.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of
the following nonpharmacological interventions should the nurse suggest to the
client to reduce pain? – ANSWER- Alternate application of heat and cold to the
affected joints.
A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse’s priority to report to the provider? – ANSWERRestlessness
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the
client’s blood and can lead to dysrhythmias or seizures. Other manifestations
include nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 4 hr postoperative following an open reduction
internal fixation of the right ankle. Which of the following assessment findings
should the nurse report to the provider? – ANSWER- Extremity cool upon
palpation
A nurse is assessing a client who is postoperative following a thyroidectomy.
Which of the following findings is the nurse’s priority? – ANSWER- Temperature
38.9° C (102° F)
A nurse is planning care for a client who is having a modified radical mastectomy
of the right breast. Which of the following interventions should the nurse include
in the plan of care? – ANSWER- Instruct the client that the drain will be removed
when there is 25 mL of output or less over a 24-hr period.
in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of
output or less in a 24-hr period.