ATI MEDSURG PROCTORED EXAM UPDATED 2021 STUDY GUIDE

ATI MEDSURG PROCTORED EXAM UPDATED 2021 STUDY GUIDE 1. The nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate? a. Teach controlled cough ...

ATI MEDSURG PROCTORED EXAM UPDATED 2021 STUDY GUIDE 1. The nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate? a. Teach controlled coughing and deep breathing b. Provide a brightly lit environment c. Elevate the head of the bed 30 degrees d. Encourage minimum intake of 2000 mL/day of clear fluids 2. A client is brought to the emergency room with a 30 percent burn over her lower extremities. Which of the following interventions should the nurse perform first? a. Clean and dress the wound b. Remove the clients clothing c. Administer a tetanus booster d. Initiate a peripheral IV 3. A nurse is caring for a client admitted to the nursing unit from the PACU following a craniotomy. The initial nursing assessment should focus on a. Intracranial pressure b. Pupillary reflexes c. Level of consciousness d. Airway patency 4. A nurse is caring for a client who has just returned from the surgical suite following a thoracotomy. Which of the following postoperative interventions should the nurse give highest priority to? a. Administer oxygen by mask via cannula at 6 L/min b. Monitor urinary output via foley catheter every 2hr c. Assess chest tube drainage hourly d. Maintain intravenous of D 5 ½ normal saline at 125 mL/hour 5. A nurse is caring for a client who has acute pancreatitis. After the client’s pain has been addressed, which of the following is next intervention to include in the plan of care? a. Monitor respiratory status every 8 hr b. Encourage a side-lying position with knees flexed c. Provide frequent oral hygiene d. Maintain NPO status 6. A nurse in the emergency department is caring for a client who has a myasthenia gravis and is in crisis. The nurse knows that which of the following factors can cause myasthenic crisis? a. Developing a respiratory infection b. Taking too much prescribed medication c. Not getting enough sleep d. Not exercising enough 7. A nurse is monitoring cardiac output on a client who has left-sided heart failure. The nurse should expect which of the following findings to compromise the readings? a. The client who has premature atrial contractions b. The client who has decreased oxygen saturations c. The client who has bilateral wheezes d. The client who has lower leg edema 8. An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing. Which of the following should the nurse expect to observe upon assessment of this client? a. Extension of the extremities b. Pronation of the hands c. Plantar flexion of the legs d. External rotation of the lower extremities 9. A client who has angina pectoris comes to the emergency department reporting chest pain. When assessing the client, which of the following findings should the nurse expect? (select all that apply) a. Weakness in the arms b. Abdominal cramps c. Diaphoresis d. Severe apprehension e. Dizziness 10. A nurse is preparing to start an intravenous infusion of lactated ringers for a client who sustained a burn injury. The client is prescribed to receive 5,200 mL of fluid over the first 24 hrs/ How many mL/hr will the nurse set the pump to infuse for the first 8 hr? a. 325 mL/hr 11. A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic reaction? a. Generalized urticarial b. Blood pressure 184/92 mmHg c. Distended jugular veins d. Bilateral flank pain 12. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck and chest. While planning the clients care, the nurse should be aware that initially the client is at greatest risk for a. Airway obstruction b. Infection c. Fluid imbalance d. Paralytic ileus 13. A nurse is caring for a client who has a blood pressure of 156/98. Which of the following finds would the client manifest with Stage 1 hypertension? a. Vertigo b. Uremia c. Blurred vision d. Dyspnea 14. A nurse is preparing to administer drotecogin alfa (Xigirs) to a client who has severe sepsis from receiving whole blood. The nurse should be aware of which of the following when giving the medication? a. Compatibility with heparin b. Parietal thromboplastin time c. Signs of hemorrhage d. Administration with NSAIDS 15. A nurse is caring for a client who is receiving a transfusion with one unit of packed cells because of blood loss during surgery. Thirty minutes after the unit of blood is hung, the client reports chills and back pain. The client’s blood pressure is 80/64 mmHg. Which of the following is the first action the nurse should take? a. Stop the infusion of blood b. Inform the provider c. Obtain a urine specimen d. Notify the Laboratory 16. A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is flushed, febrile, and having chills. To establish a diagnosis of hemolytic transfusion reaction, the nurse should assess the client for which of the following? a. Headache b. Anxiety c. Urticaria d. Flank pain 17. A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow coma scale score of 3 for eye opening, 5 for best verbal response, and 5 for the best motor response. Which of the following is an appropriate conclusion based on this data? a. The client can follow simple motor commands b. The client is unstable to make vocal sound c. The client is unconscious d. The client opens his eyes when spoken to 18. A nurse is reading a clients ECG tracing. There are nine QRS complexes in a 6 second interval. What is the client’s heart rate? a. 90/min 19. A nurse is caring for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client’s plan of care? a. Ability to achieve independent transfer from bed to wheelchair b. Independent control of bowel and bladder function c. Use of a wheelchair with a chin or mouth stick d. Ability to self-feed with the use of adaptive equipment 20. A nurse is monitoring a client who has an anterior septal myocardial infarction. The client is on a dobutamine hydrochloride (Dobutrex) drip. The nurse understands the rationale for the clients dobutamine drip is to a. Dilate veins and arteries b. Improve cardiac output c. Reduce hypertension d. Reduce heart rate 21. A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements by the nurse is appropriate? a. This device is use to treat injury to the lumbar spine b. The purpose of this device is to immobilize the cervical spine c. This device provides pain relief through compression of the spinal nerves d. The purpose of this device is to allow for neck movement during the healing process. 22. A nurse is planning preventative care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following is an appropriate nursing action? a. Apply restraints b. Administer opioids c. Darken the room d. Reduce stimuli 23. A nurse is teaching a client who has rheumatoid arthritis about self-care techniques. Which of the following strategies should she include to illustrate the concept of joint protection? a. Press water from a sponge rather than wringing it b. Lift objects instead of sliding or pushing them c. Finish weekly household tasks within 1 or 2 days d. Engage in repetitive tasks that keep the joints mobile. 24. A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? a. A dry, hacking cough b. Hepatomegaly c. Dizziness d. Crackles 25. A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client’s IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse? a. Slow the rate to 20 mL/hr b. Continue the rate at 125 mL/hr c. Slow the rate to 50 mL/hr d. Increase the rate to 250 mL/hr 26. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? a. Confusion b. Lethargy c. Unconsciousness d. Petechiae 27. A nurse is preparing a client for a barium swallow to evaluate dysphagia. Which statement indicates to the nurse that the client understands the instructions? a. I should take all my oral medications before I come in the morning b. I will drink plenty of fluids the morning of the tests c. I will remove my metal jewelry before coming in for the test d. I will bring a snack because ill be here all day 28. A nurse is caring for a client who has bleeding esophageal varices treat with a sengstaken-blakemore tube. Which of the following nursing actions is appropriate for the nurse to perform? a. Deflate the balloons for 5 mins ever 2 hrs to prevent tissue necrosis b. Maintain constant observation wile the balloons are inflated c. Suction the tube every 2 hrs and as needed to maintain patency d. Keep the head of the bed flat at all times to prevent development of shock 29. A nurse on a medical unit is caring for a client who has infective endocarditis. The nurse should observe this client for manifestations of a common complication of this disorder by monitoring for a. A heart murmur b. Dyspnea c. Fever d. Petechiae 30. A client who is taking medications to treat hypertension has potassium level of 6.8 mEq/L. Besides notifying the provider, which of the following actions should the nurse take? a. Suggest that the client use a salt substitute b. Obtain a 12-lead ECG c. Advice the client to add citrus juices and bananas to her diet d. Obtain a blood sample for a serum sodium level 31. The nurse is caring for a client who is receiving treatment following a motor vehicle crash. Which of the following is appropriate for determining the client’s alertness? a. Check clients eye opening in response to verbal stimuli b. Check pupillary response to light c. Check clients motor response to nail bed pressure d. Check clients response to questions about place and time 32. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires a. a cardiology consult b. less frequent suctioning c. an antidysrhythmic medication d. pre-oxygenation prior to suctioning 33. A nurse is assessing the effectiveness of elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should alert the nurse to a possible complication? a. Pitting edema around the stump dressing b. Looseness of the stump dressing c. The dressing forming a cone shape over the stump d. Figure-eight wrapping around the stump 34. A nurse caring for a client who reports pleuritic pain on the right side. The nurse notices that the client has dyspnea, decreased movement of the chest wall, and absent breath sounds on the right ride. The nurse should suspect that the client has which of the following? a. Pleural effusion b. Pulmonary embolism c. Pulmonary infection d. Empyema 35. A nurse suspects a client with myasthenia gravis is experiencing myasthenic crisis. Which of the following interventions is appropriate? a. Prepare the client for mechanical ventilation b. Administer an anticholinesterase medication c. Instruct the client to perform the pursed lip breathing d. Schedule the client for immediate dialysis 36. A client arrives at the emergency department following an explosion at a chemical plant. He has deep partial and full thickness chemical burns over more than 25% of his body surface area. What is the nurse’s priority intervention for this client? a. Initiate fluid resuscitation b. Medicate for pain c. Administer antibiotics d. Maintain a patent airway 37. In preparation for the discharge of a client with PAD, the nurse should include which of the following instructions? a. Apply a heating pad on a low setting to help relieve leg pain b. Adjust the thermostat so that the environment is warm c. Wear antiembolic stocking during the day d. Rest with legs above the heart level 38. A client tells the nurse at the clinic that she thinks she might be developing rheumatoid arthritis because she has some stiffness in her joints. Which other early manifestation of RA should the nurse expect to find when she assesses the client? a. Muscle atrophy b. Fatigue c. Temporomandibular joint pain d. Decrease ROM 39. A nurse is creating plan of care for a client who has advanced cirrhosis. Which of the following manifestation should the nurse expect to find? a. Petechiae b. Vitamin C deficiency c. Osteoarthritis d. Peripheral ulcers 40. A nurse on a critical care unit is caring for a client who has shallow and rapid respirations, paradoxical pulse, CVP 4 cm H2O, BP 90/50 mmHg, skin cold and pale, and urinary output 55mL over the last 2 hr. From these findings the nurse concludes that he may be developing which of the following? a. Hypovolemic shock b. Cardiac tamponade c. Sepsis d. Atelectasis 41. A nurse implementing a plan of care for a client who had a craniotomy to clip a cerebral aneurysm. Which of the following postoperative complication should the nurse anticipate? a. Hypernatremia b. Oliguria c. Hypoglycemia d. Polyuria 42. A nurse caring for a client who has a quadriplegia from a spinal cord injury who reports having a “severe headache”. Upon assessment the nurse obtains a blood pressure reading of 210/108 mmHg. Suspecting the client is experiencing autonomic dysreflexia, which of the following actions should the nurse perform first? a. Administer a nitrate antihypertensive b. Assess the client for bladder distention c. Place the client in high-fowler’s position d. Obtain the client heart rate 43. A nurse is assessing a client who has systemic lupus erythematosus. Which of the following findings is the highest priority to report to the provider? a. Client report of feelings of depression b. Dry, raised rash on the face c. Presence of peripheral edema d. Joint pain in hands and knees 44. A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply) a. Count your pulse for min each morning b. Count your respiratory rate for 1 min each morning c. Do not wear tight clothing over the insertion area d. Avoid coming into contact with metal detectors e. Do not operate microwave ovens 45. A client who has undergone a right below-the-knee amputation due to trauma now has a prosthetic limb. When teaching the client about prosthesis and stump care, the nurse should include which of the following instructions? a. Keep the prosthesis in direct contact with the limb b. Apply a moisturizing lotion or oil to the stump daily c. Dry the prosthesis socket completely before applying it to the limb d. Expect some skin irritation from the prosthesis 46. A nurse is teaching an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is a. Increased urine output b. Rapid pulse c. Fatigue d. Sneezing 47. A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes sulfonate (kayexalate). If this medication is effective the nurse should expect which of the following corrections on the clients ECG? a. Reduction of T wave amplitude b. Reduction of P wave duration c. Widening of the QRS complex d. Restoration of QRS complex amplitude 48. A nurse enters an adult client’s room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? a. Summon the code team b. Begin chest compressions c. Administer rescue breathing d. Open the client’s airway 49. A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse identifies these findings as indicators of which of the following complications? a. Dialysis disequilibrium b. Air embolism c. Peritonitis d. Septicemia 50. A nurse is caring for a female client who came to the emergency department reporting shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate is 40/min, and blood pressure 140/80 mmHg. Her arterial blood gases are pH: 7.50, PaCO2 29, OaO2 60, HCO3 20SaO2 86. Which of the following is the priority intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Monitor for pulmonary embolism 51. A nurse is caring for a client who is receiving mechanical ventilation. When the nurse assesses the client she need to know that the expected tidal volume for a client receiving mechanical ventilation is a. 5 to 7 mL/kg b. 7 to 9 c. 9 to 11 d. 11 to 13 52. A client comes to the ED via ambulance to report severe radiating chest pain and SOB. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4L/min stat, cardiac enzyme levels, fluids, and a 12 lead ECG. Which of the following actins should the nurse take first? a. Attach the leads a 12 lead ECG b. Obtain the blood sample c. Initiate oxygen therapy d. Insert the IV catheter 53. A nurse is preparing to transfuse a client with a unit of RBC. During the first 15 min, which of the following infusion rates should the nurse start the RBC at? a. 10 mL/min b. 5 mL/min c. 40 mL/min d. 20 mL/min 54. A nurse is planning care for a client who has acute glomerulonephritis related to a streptococcal infection. Which of the following interventions is appropriate to include in the plan of care? a. Administer prescribed antibiotics b. Encourage increased fluid intake c. Obtain weekly weight d. Encourage frequent ambulation 55. A nurse is caring for a client following a renal biopsy. Which of the following interventions are appropriate? (select all that apply) a. Monitor for hematuria b. Check for flank pain c. Monitor for extravasation of tissue surrounding the biopsy site d. Encourage ambulation e. Administer aspirin PRN for pain CONTINUED....DOWNLOAD FOR BEST SCORES