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ATI RN Adult Medical Surgical
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ATI RN Adult Medical Surgical
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RN Adult Medical Surgical Nursing Review Module
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ATI RN Adult Medical Surgical Proctored 2019 A ExamA nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
ANSWER: Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce
the risk for thromboembolism and promote venous return.
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? -
ANSWER: Bubbling in the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic
atrial fibrillation. Which of the following values should the nurse identify as a desired
outcome for this therapy? - ANSWER: INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial
infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an
anticoagulant, the medication must be monitored to ensure the anticoagulation is
within the therapeutic range and prevent hemorrhage (high levels of
anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is
within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
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
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the hips
when in a lateral position to no more than 30°. This positioning prevents direct
pressure on the trochanter.
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? - ANSWER:
Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is restlessness, which
can be an indication the client is experiencing disequilibrium syndrome.
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 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ANSWER: Scan the bladder with a portable
ultrasound.
, Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders presents
the greatest risk to this group of clients? - ANSWER: Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
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? - ANSWER: Glucose 272
mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min.
ago. Which of the following findings should the nurse report to the provider
immediately? - ANSWER: Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is stridor. Stridor can indicate a narrowing airway
or possible obstruction caused by edema or laryngeal spasms. The nurse should
report the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago.
Which of the following findings should the nurse report to the provider? - ANSWER:
The client reports back pain
Rationale: The nurse should notify the provider if the client reports back pain, which
can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANSWER: Airborne
Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such
as tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical
cancer. Which of the following interventions should the nurse include in the plan of
care? - ANSWER: Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's
room in case of accidental dislodgement of the implant.
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)
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