Free ATI Medical Surgical practice for ATI Medical Surgical Proctored Exam 2023 (ATI RN). Answer 49 nursing exam-style questions with rationales, exam mode, and
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
Select the best answer.
Explanation:
When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.
A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?
Select the best answer.
Explanation:
The best response is to encourage the newly graduated nurse to actively participate in quality improvement initiatives. Being new does not preclude one from contributing to improving care processes and outcomes. By engaging in small activities focused on quality improvement, the new nurse can start making a positive impact and learn valuable skills early in their career.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
Select the best answer.
Explanation:
An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.
How can a nurse manager best improve hand-off communication among the staff? (SATA)
Select the best answer.
Explanation:
The SHARE model is a valuable tool for standardizing hand-off reports and other critical communication. By utilizing this model, the nurse manager can ensure consistency and clarity in hand-off communication among the staff. While attending hand-off rounds to coach and mentor, conducting audits using a new template, and creating a template of topics to include in the report can all be beneficial actions, the most effective approach to achieve the goal of improving hand-off communication is by implementing a standardized tool like the SHARE model.
A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?
Select the best answer.
Explanation:
In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.
When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?
Select the best answer.
Explanation:
When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.
When teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition, what information should be included? (Select all that apply)
Select the best answer.
Explanation:
When educating a client with COPD about nutrition, it is important to consider factors that can impact breathing and digestion. Avoiding drinking fluids just before and during meals can help prevent bloating, which may impede breathing. Resting before meals if experiencing dyspnea can aid in reducing respiratory effort during eating. Having about six small meals a day can help prevent overeating and decrease the feeling of fullness, promoting easier breathing. However, it is crucial to be cautious with high-fiber foods as they can produce gas, leading to abdominal bloating and increased shortness of breath. Clients with COPD should focus on increasing calorie and protein intake to prevent malnourishment. It is advisable not to increase carbohydrate intake as this can elevate carbon dioxide production and exacerbate breathing difficulties.
A client with newly diagnosed osteoporosis is being taught about lifestyle modifications. Which instruction should be included?
Select the best answer.
Explanation:
Engaging in weight-bearing exercises is crucial for individuals with osteoporosis as it helps strengthen bones and reduce the risk of fractures. Weight-bearing exercises include activities like walking, jogging, dancing, and strength training. These exercises help improve bone density and overall bone health, making them an essential component of lifestyle modifications for individuals with osteoporosis.
A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
Select the best answer.
Explanation:
The client's symptoms of a pounding headache and blurred vision are indicative of autonomic dysreflexia, a potentially life-threatening condition in clients with spinal cord injuries at T6 or above. The nurse's priority action should be to check the client's blood pressure as autonomic dysreflexia can lead to severe hypertension. Identifying and addressing this elevated blood pressure promptly is crucial to prevent serious complications such as seizures, stroke, or even death. Once the blood pressure is assessed and managed, further interventions can be implemented to address the underlying cause of autonomic dysreflexia.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.
During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
Select the best answer.
Explanation:
Confusion is a common manifestation of pneumonia in older adults. It can result from inadequate oxygenation to the brain due to respiratory compromise. Bradycardia, night sweats, and narrowed pulse pressure are not typically specific findings associated with pneumonia and should be further assessed or monitored, but confusion is a key indicator that warrants immediate attention.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
Select the best answer.
Explanation:
Gastroenteritis can lead to fluid loss through vomiting and diarrhea, especially when accompanied by fever. Fever can increase insensible water loss through sweating as well. Both vomiting and diarrhea can significantly contribute to fluid volume deficit, making the client with gastroenteritis and fever at higher risk compared to the other clients described in the options.
During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?
Select the best answer.
Explanation:
When a client is positioned on the left side in Trendelenburg position for pulmonary hygiene, secretions are expected to be mobilized from the lateral segment of the right lower lobe. This positioning helps facilitate drainage and clearance of secretions from this specific area of the lung, aiding in overall pulmonary hygiene and improving ventilation.
A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?
Select the best answer.
Explanation:
In a client who has undergone intermaxillary fixation for facial fractures, wire cutters are essential equipment to have at the bedside in case of emergencies such as airway compromise. These wire cutters allow prompt removal of the wires securing the jaw if needed to ensure adequate airway patency. NG tube, urinary catheter tray, and IV infusion pump are important pieces of equipment in various clinical scenarios but are not specifically required for managing intermaxillary fixation postoperatively.
Prior to a thoracentesis, what intervention should the nurse complete?
Select the best answer.
Explanation:
Before a thoracentesis procedure, it is crucial to ensure that the client has given informed consent. This process involves explaining the procedure, its risks, benefits, and alternatives to the client, and obtaining their signature on the consent form. Verifying informed consent is a vital legal and ethical step to protect the client's autonomy and ensure they have made an informed decision about the procedure.
A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
Select the best answer.
Explanation:
To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.
A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
Select the best answer.
Explanation:
Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
Select the best answer.
Explanation:
Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.
A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
Select the best answer.
Explanation:
Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
Select the best answer.
Explanation:
When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
Select the best answer.
Explanation:
Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
Select the best answer.
Explanation:
Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.
A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?
Select the best answer.
Explanation:
When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.
What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
Select the best answer.
Explanation:
The correct answer is B. A nurse should ask the client if they have any chronic breathing problems when the anteroposterior (AP) chest diameter is the same as the lateral chest diameter. This finding indicates a barrel chest, which can be associated with chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) or emphysema. Assessing for chronic breathing problems can help the nurse further evaluate the client's respiratory status and provide appropriate care.
A student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select one that does not apply)
Select the best answer.
Explanation:
Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease, as they can be changed or controlled through interventions. Age, on the other hand, is a nonmodifiable risk factor, meaning it cannot be altered. Understanding the difference between modifiable and nonmodifiable risk factors is essential in preventive healthcare strategies.
A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?
Select the best answer.
Explanation:
Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.
A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
Select the best answer.
Explanation:
Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.
A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
Select the best answer.
Explanation:
Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.
A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)
Select the best answer.
Explanation:
The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.
When admitting a client with active tuberculosis to a room on a medical-surgical unit, which of the following room assignments should the nurse make?
Select the best answer.
Explanation:
When admitting a client with active tuberculosis, it is crucial to assign them to a room with air exhaust directly to the outdoor environment to prevent the spread of infectious particles to other patients and healthcare workers. This setup helps in reducing the risk of transmission within the healthcare facility. Placing the client in a room with another nonsurgical client or in the ICU may increase the chances of spreading the infection. Additionally, placing the client in a room within view of the nurses' station does not address the need for proper ventilation to minimize transmission of tuberculosis.
A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
In a three-chamber chest drainage system, the absence of bubbling in the suction control chamber indicates that no suction is being applied to the chest tube. The nurse should first verify that the suction regulator is on and check the tubing for any leaks that may be causing the lack of suction. Adding more water to the chamber or milking the chest tube are inappropriate actions and could potentially harm the client. Monitoring the client without taking action could lead to complications if the chest tube is not functioning properly.
A healthcare professional is assessing a client with left-sided heart failure. Which finding is most commonly associated with this condition?
Select the best answer.
Explanation:
Crackles in the lungs are commonly associated with left-sided heart failure due to pulmonary congestion. Left-sided heart failure leads to the backup of blood into the lungs, causing fluid leakage into the alveoli, which results in the characteristic crackling sound upon auscultation.
A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?
Select the best answer.
Explanation:
Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.
Which action best demonstrates respect for autonomy when working with a client?
Select the best answer.
Explanation:
Respect for autonomy involves allowing individuals to make decisions about their care. By asking if the client has questions before signing a consent form, the nurse is respecting the client's right to make informed choices and decisions regarding their healthcare. This action supports the principle of self-determination and autonomy in healthcare decision-making.
A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?
Select the best answer.
Explanation:
Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
Select the best answer.
Explanation:
The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
Select the best answer.
Explanation:
The client joining a book club that meets outside the home and requires him or her to go out in public is the best indicator that goals for Impaired Self-Esteem are being met. This social activity indicates an improvement in self-confidence and willingness to engage with others, which are essential aspects of self-esteem. The other choices, while positive, do not directly address self-esteem concerns related to social interaction and confidence.
A client with chronic obstructive pulmonary disease (COPD) is being taught by a healthcare provider. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
The correct answer is C. While exercise is important for clients with COPD, daily exercise may be too strenuous. Clients should be encouraged to exercise regularly but should be advised to avoid overexertion. Statements A, B, and D demonstrate appropriate understanding and management of COPD symptoms.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
Select the best answer.
Explanation:
Assessing for signs of bleeding is the priority when caring for a client with deep vein thrombosis (DVT) receiving heparin therapy. Heparin therapy increases the risk of bleeding complications, so monitoring for signs of bleeding is crucial to ensure patient safety and timely intervention if needed.
A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?
Select the best answer.
Explanation:
Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.
A client in a clinic presents with an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
Select the best answer.
Explanation:
During an acute asthma exacerbation, the preferred medication for symptom relief is a short-acting beta-agonist like albuterol, typically delivered via a jet nebulizer for quick onset and efficacy. Cromolyn, montelukast, and budesonide are not as effective for immediate symptom relief in acute exacerbations and are more commonly used for prevention or long-term management of asthma symptoms.
A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?
Select the best answer.
Explanation:
Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.
A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Select the best answer.
Explanation:
Continuous bubbling in the water-seal chamber indicates air is leaking into the pleural space, which is a complication. The water-seal chamber should have intermittent bubbling during normal functioning. Occasional bubbling in the water-seal chamber is normal and shows the system is working as intended. Constant bubbling in the suction-control chamber suggests an issue with the suction control. Fluctuations in the fluid level in the water-seal chamber are an expected finding.
A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?
Select the best answer.
Explanation:
Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
Select the best answer.
Explanation:
A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
Select the best answer.
Explanation:
Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.
A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)
Select the best answer.
Explanation:
Interdisciplinary work in healthcare involves effective communication and collaboration between different disciplines for holistic client care. Consulting with other disciplines allows for sharing expertise, insights, and perspectives to enhance client outcomes. Participating in comprehensive client rounding involves a team-based approach to discuss and plan client care collectively. Sharing nursing care plans with other disciplines ensures that all team members are informed and can contribute to the client's overall well-being. Coordinating discharge planning is important but may not directly demonstrate interdisciplinary collaboration as the other actions do.
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Select the best answer.
Explanation:
When the nurse observes the absence of left-sided chest wall expansion upon respiration, it indicates that the endotracheal tube (ET) may have migrated into the right main bronchus, leading to uneven chest expansion. This can result in inadequate ventilation to the left lung, causing respiratory compromise. The other options, such as blockage of the ET tube by the client's tongue, passage of the ET tube into the esophagus, and infection of the vocal cords, do not directly explain the observed chest wall asymmetry and respiratory distress.
When caring for a client with Alzheimer's disease, what is the most appropriate communication technique for a nurse to use?
Select the best answer.
Explanation:
When communicating with clients with Alzheimer's disease, using simple and direct statements is the most appropriate technique. This approach helps to minimize confusion, enhance understanding, and facilitate effective communication with individuals who may have difficulty processing complex information due to their condition.
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