Preview Extract
ATI Medical Surgical Real Exam 101 Questions and Correct Answers (Verified
Answers)|AGrade
A nurse is providing discharge teaching to a client who has a new prescription for sublingual
nitroglycerin. Which of the following client statements indicates an understanding of the
teaching?
Answer: I should lie down when I take this medication
A nurse is providing discharge teaching to an older adult client following total hip arthroplasty.
Which of the following instructions should the nurse include in the teaching?
Answer: Install a raised toilet seat in your bathroom
A nurse is planning care for a client following a cardiac catheterization. Which of the following
actions should the nurse take?
Answer: Maintain the client's affected extremity in extension
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?
Answer: I will need to have my partner take over shopping for groceries and cooking the meals
for us
A nurse is providing teaching to a client who has an impaired immune system due to
chemotherapy. which of the following information should the nurse include in the teaching?
Answer: Change your pet's litter box daily
a nurse is caring for a client who has a contusion and reports thirst. The client's urinary output
was 4,000 ml over past 24 hr. the nurse should anticipate a prescription for which of the
following IV medications?
Answer: Desmopressin
A nurse in a clinic receives a phone call from a client who recently started therapy with an ACE
inhibitor and reports nagging dry cough. Which of the following responses by the nurse is
appropriate?
Answer: Sucking on a lozenge may reduce the frequency of your cough
A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the
following assessment findings should the nurse identify as a parenteral trigger for exacerbation
of Raynaud's?
Answer: Using nicotine transdermal patch
A nurse is caring for a client who has a central venous device and notes the tubing has become
disconnected. the client develops dyspnea and tachycardia. Which of the following actions
should the nurse take first?
Answer: Clamp the catheter
A nurse is completing an assessment of an older client and notes reddened areas over the bony
prominences, but the client's skin is intact. which of the following interventions should the nurse
include in the plan of care?
Answer: Support bony prominences with pillows
A home health nurse is making an initial visit to a client who has multiple sclerosis. Which of the
following actions is the priority for the nurse to take?
Answer: Provide coping strategies for client and family
A nurse in the emergency department is assessing a client. which of the following actions should
the nurse take first? (click on the "exhibit" button for additional information about the client.)
Answer: Initiate airborne precautions
A nurse is reviewing the medical record of a client to identify factors for colorectal cancer. The
nurse should identify which of the following findings as increasing the client's risk?
Answer: History of Crohn's disease
A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm
not sure I want to have a mastectomy." Which of the following statements should the nurse
make?
Answer: I can give you additional information about the procedure
A nurse is preparing to administer a unit of packed RBCs to a client who is anemic. Identify the
sequence of steps the nurse should follow
Answer: 1. obtain venous access using a 19gauge needle
2. Obtain the unit of a packed RBCs from blood bank
3. verify blood compatibility with another nurse
4. Initiate transfusion of the unit of packed RBCs
5. Remain with the client for the first 15 to 30 minutes
A nurse is providing discharge teaching to a client following a modified left radical mastectomy
with breast expander. Which of the following statements by the client indicates an understanding
of the teaching?
Answer: I should expect less than 25 ml of secretions per day in the drainage devices
A critical care nurse is assessing a client who has a severe head injury. In response to painful
stimuli, the client does not open her eyes, displays decerebrate posturing and makes
incomprehensible sounds. which of the following Glasgow Coma scale scores should the nurse
assign the client?
Answer: 5
A nurse is providing discharge teaching to a client who has heart failure and instructs him to
limit sodium intake to 2 g per day. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: I can have a frozen fruit juice bar for dessert
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the
eye. Which of the following actions should the nurse plan to take first?
Answer: instill 0.9% sodium chloride solution into the affected eye
A nurse is assessing a client following extubation from a ventilator. For which of the following
findings should the nurse intervene immediately?
Answer: Stridor
A nurse is reviewing the laboratory reports of a client who has acute pancreatitis. Which of the
following findings should the nurse expect?
Answer: Elevated blood glucose
A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the
following findings should the nurse expect?
Answer: Urine specific gravity 1.001
A nurse is planning care for a client who has a pulmonary embolism. which of the following
interventions should the nurse include?
Answer: Initiate a continuous IV heparin infusion
a nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis.
which of the following instructions should the nurse include?
Answer: Avoid extremely hot or cold temperatures
A nurse in the emergency department is caring for a client who is in hypovolemic shock. Which
of the following actions should the nurse take first?
Answer: Insert a large-bore IV catheter
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings
indicates adequate circulation on of the graft?
Answer: Palpable thrill
A nurse is assessing a client who has heart failure and is receiving a loop diuretic. Which of the
following finding indicates hypokalemia?
Answer: Muscle weakness
A nurse is caring for a client in diabetic ketoacidosis (DKA) Which of the following is the
priority intervention by the nurse?
Answer: Infuse 0.9% normal saline
A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following
client statements indicates an understanding of the teaching?
Answer: I will expect my stools to be loose
A nurse is caring for a client who is receiving total parenteral nutrition through a central line. The
current bag is nearly empty, and a new bag is unavailable from the pharmacy. Which of the
following actions should the nurse take?
Answer: Switch the infusion to a 10% dextrose solution
A nurse is caring for a client who is 6hr postoperative following a thyroidectomy. The client
reports tingling and numbness in the hands. The nurse should identify this as a sign of which of
the following electrolyte imbalance?
Answer: Hypocalcemia
A nurse in a provider office is caring for a client who has total vision loss and is the handler of a
service dog. which of the following actions should the nurse take to show consideration for the
client and the service animal?
Answer: Consult the client before approaching the dog.
A nurse is reviewing medications taken at home with a client who has angina. which of the
following statements by the client indicates an understanding of the teaching?
Answer: I should lie down before taking a dose of isosorbide dinitrate
A nurse in the post anesthesia care unit is assessing a client following an appendectomy and finds
a 2 cm (3/4 in) area of blood on the postoperative dressing. which of the following actions should
the nurse take?
Answer: Apply pressure
A nurse is caring for a client who is receiving mechanical ventilation. which of the following
interventions should the nurse implement?
Answer: Provide oral care every 2 hr
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?
Answer: Apply new gloves when alternating between wound care sites.
A nurse is providing teaching for a client who has tuberculosis and a new prescription for
pyrazinamide. The nurse should instruct the client to notify the provider if which of the
following adverse effects occurs?
Answer: Jaundice
A nurse is planning care for a client who has left-side hemiplegia following a stroke. which of
the following actions should the nurse include in the plan of care?
Answer: Place a plate guard on the client's meal tray
A nurse is performing an ear irrigation for a client. Which of the following actions should the
nurse take?
Answer: Point the tip of the syringe toward the top of the ear canal
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting.
Which of the following medications should the nurse administer prior to chemotherapy?
Answer: Ondansetron
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?
Answer: May operate a motor vehicle when no longer taking analgesics
A nurse is providing discharge teaching to a client who has tuberculosis. Which of the following
information should the nurse include in the teaching?
Answer: You will return in 2 weeks to provide a sputum specimen.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect?
Answer: Frothy sputum
A nurse is planning care for a client who has osteoarthritis of the knees. Which of the following
interventions should the nurse include in the plan?
Answer: Place a large pillow under the client's knees when resting.
A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain.
Which of the following actions should the nurse take first?
Answer: Check the client's urine output
A nurse is caring for a client who is receiving chemotherapy and requests information about
acupuncture to relieve some of the side effects. which of the following findings should the nurse
identify as a contraindication to receiving this alternative therapy?
Answer: Lymphedema
A nurse is preparing to administer lactated Ringer's via continuous IV infusion at 200 ml/hr. The
IV tubing has a drop factor of 10 drops/mL. How many gtt/min should the nurse set the IV ump
to administer?
Answer: 33
A nurse is providing instructions about foot care for a client who has a peripheral arterial disease.
The nurse should identify that which of the following statements by the client indications
understanding of the teaching
Answer: "I rest in my recliner with my feet elevated for about an hour every afternoon"
A nurse in a provider's office is teaching a client about the self-management of GERD. Which of
the following instructions should the nurse include?
Answer: Sleep with the head of the bed elevated 6 inches
A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of
the following findings is the priority for the nurse to report to the provider?
Answer: Highpitched sound on inspiration
A nurse is caring for a client who is 2 days postoperative following a below the knee amputation
and asks about the purpose of maintaining an elastic bandage around the residual limb of the
extremity. Which of the following is an appropriate response by the nurse?
Answer: The elastic bandage will prevent edema
A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass
grafting. which of the following assessments should the nurse plan to perform first?
Answer: Measure the client's core body temperature
A nurse is providing instructions to a client who has primary syphilis. Which of the following
instructions should the nurse include in the discharge plan?
Answer: You will need to be monitor for 15 minutes after receiving each medication close
A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the client?
Answer: Feet elevated
A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the
nurse expect as an indication the wound is healing?
Answer: Dark red granulation tissue
A nurse is providing discharge teaching for a client who has a new tracheostomy. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: I'll cut a slit in a clean gauze pad to use as a stoma dressing
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 contraindication on for receiving
the medica on?
Answer: Potassium 3.2 mEq/L
A nurse is caring for a client admitted with a skull fracture. which of the following assessment
findings should be greatest concern to the nurse?
Answer: Glasgow coma scale score changes from 14 to 9
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements
should indicate to the nurse that the client needs a referral for occupational therapy?
Answer: I have a hard time with brushing my hair
A nurse is providing discharge teaching to a client who will be self-administering insulin at
home. Which of the following information on should the nurse include regarding needle
disposal?
Answer: You can discard needles in an empty bleach bottle with a lid
A nurse is assessing a client who has an arteriovenous (AV) graft in the left forearm. Which of
the following findings should indicate to the nurse a complication on of vascular access?
Answer: Absence of a bruit
A client who is ideal and communicates using sign language is being admitted by a nurse who
does not know sign language. Which of the following actions should the nurse take?
Answer: Request an interpreter during the initial assessment
A nurse is teaching a client. about the nurse of the incentive spirometer. which of the following
instructions should the nurse include in the teaching?
Answer: Hold breaths 3 to 5 seconds before exhaling
A nurse is caring for a client who sustained a spinal cord injury in a diving accident. which of the
following actions should the nurse take?
Answer: Monitor urine output hourly
A nurse is planning care for a client who has a central venous access device for intermittent
infusions. Which of the following actions should the nurse include in the plan of care?
Answer: Flush the catheter using a 10 ml syringe
A nurse in the emergency department is caring for a client who has a gunshot wound to the
abdomen. Which of the following action should the nurse take first?
Answer: Remove all of the client's clothing
A nurse is caring for a client following a bronchoscopy. Which of the following action should the
nurse take first?
Answer: Check the client's gag reflex
A nurse is teaching a client about using a metered-dose rescue inhaler. which of the following
statements should the nurse include in the teaching?
Answer: Exhale fully before bringing the inhaler to your lips
A nurse is instructing a client who has a new diagnosis of type 1 diabetes mellitus about the sickday rules. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: I will check my urine for ketones if my blood glucose is greater than 240 mg/dL
A nurse is reviewing ABG results for a client who has COPD. Which of the following findings
should the nurse expect?
Answer: PaCO2 48 mm Hg
A nurse is admi ng a client to a medical unit following placement of a permanent pacemaker.
Which of the following findings requires further assessment by the nurse?
Answer: Hiccups
A nurse is preparing to administer daily medications to a client who is undergoing a procedure at
1000 that requires IV contrast dye. which of the following routine medications to give at 0800
should the nurse withhold?
Answer: Metformin
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?
Answer: Apply compression stocking socks
A nurse is caring for a client who has duodenal ulcer. which of the following actions should the
nurse take? (click on the Exhibit button for additional information.)
Answer: Infuse packed RBCs
A nurse is assessing an older adult client at a health fair. Which of the following statements by
the client is the nurse's priority?
Answer: In the last day, I have had a severe headache and pain around my right eye.
A nurse is caring for an adolescent client who has an acute kidney injury. Which of the following
laboratory findings should the nurse anticipate?
Answer: Potassium 6.8 mEq/L
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?
Answer: Encourage the client to change positions slowly
A nurse is preparing to receive a client from surgery following a transverse colon resection with
colostomy placement. The nurse should expect assess the stoma at which of the following
locations?
Answer: On top
A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen.
Which of the following actions should the nurse take to help prevent the onset of acute kidney
failure?
Answer: Administer IV fluids to the client
A nurse is preparing to administer 1 unit of packed RBCs to an adult client. Which of the
following actions should the nurse plan to take?
Answer: Complete the infusion within 2 hr
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the
following dietary recommendations should the nurse include?
Answer: Decrease protein intake
A nurse is caring for an older adult client who has dementia. Which of the following questions
should the nurse ask to assess the client's abstract thinking?
Answer: What is mean by the saying "Don't beat around the bush?"
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of
the following actions should the nurse take?
Answer: Keep soiled bed linens in the client's room
A nurse is preparing a client for a lumbar puncture which of the following images indicates the
position the nurse should assist the client into for this procedure?
Answer: fetal position
A nurse is caring for a client who has cervical cancer and a sealed radiation implant. Which of
the following actions should the nurse take?
Answer: Attach a dosimeter badge to the client's gown
A nurse is teaching a client who has Grave's disease about recognizing the manifestations of
thyroid storm. Which of the following findings should the nurse include in the teaching?
Answer: Increased temperature
A nurse is caring for a client who is postoperative following a complete thyroidectomy, which of
the following findings is the priority for the nurse to report to the provider?
Answer: Muscle twitching
A nurse is reviewing ECG rhythm strips for a group of clients. the nurse should identify that
which of the following rhythms indicates bradycardia?
Answer: The nurse should identify sinus bradycardia, characterized by a regular rhythm with a
heart rate below 60 beats per minute, as indicating bradycardia.
A nurse is caring for a client who is receiving epidural analgesia. Which of the following
assessment finding is the nurse's priority?
Answer: Hypotension
A nurse is planning care for a client who has status epilepticus. Which of the following
interventions is the nurse's priority to include?
Answer: Turn the client lateral position during the seizure activity.
A nurse is caring for a client following a below the knee amputation. The client states, "my life is
over". Which of the following responses should the nurse take?
Answer: Why do you think your life is over?
A nurse in a clinic is providing preventive teaching to an older adult client during a well visit.
The nurse should instruct the client that which of the following immunizations are recommended
for healthy adult after age 60?
Answer: 1. Pneumococcal polysaccharide
2. Herpes zoster
3. Influenza
A nurse is planning care a client who has dementia. Which of the following interventions should
the nurse plan to include?
Answer: Assist the client with toiling at least once every 4 hr
A nurse is assessing a client who has new diagnosis of DM1. Which of the following findings
indicate that the client is experiencing hypoglycemia?
Answer: Increased perspiration
A nurse in the PACU is assessing a client who is post-operative following general anesthesia.
Which of the following findings is the priority to address?
Answer: vomiting upon arousal
A nurse is caring for a client who has hypervolemia. Which of the following is an expected
assessment finding?
Answer: Weight gain
A nurse is teaching about measure to prevent recuring urinary tract infections with a female
client. Which of the following information should the nurse include in the teaching?
Answer: • Wipe the perineal area from front to back after urinating.
• Drink 3L of fluids daily
• Drink low-fructose cranberry juice
A nurse is caring for a client following a cardiac-catherization who has hives and urticaria
following administration of IV contrast dye. Which of the following Medication should the nurse
plan to administer?
Answer: Diphenhydramine
A home care nurse to use non-pharmacological pain relief measures for an adult client who has
severe chronic back pain. which of the following guideline should the nurse use?
Answer: Discontinue opioids before trying nonpharmacological methods of pain relief
A nurse is caring for a female client who is receiving total parenteral nutrition without fat
emulsion. Which of the following findings should the nurse report?
Answer: Crackles in the bilateral lung bases
A nurse is caring for a client who has a lower extremity fracture and a prescription for crutches.
Which of the following client statements indicate that client is adapting to the role of change?
Answer: i will need my partner to take over shopping for groceries
