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ATI Proctored Med Surg – QUESTION AND ANSWERS | LATEST UPDATE 2024 | 2025 WITH COMPLETE SOLUTIONS
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ATI Proctored Med Surg – QUESTION AND ANSWERS | LATEST UPDATE 2024 | 2025 WITH COMPLETE SOLUTIONS
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ATI Proctored Med SurgA hospice nurse is planning end-of-life comfort care for a client. Which of the following
interventions should the nurse include in the plan?
A. Cover the client with an electric blanket if extremities become mottled
B. Provide frequent feedings during the day
C. Position the client on their side to improve breathing
D. Remove visitors from the room if the Clint becomes restless - ANS-C
Position laterally to improve breathing and promote comfort
A n urse at a urgent care clinic is caring for a client who is experiencing an anaphylactic
reaction. After ensuring a patent airway, which of the following nursing interventions is the
priority?
A. Applying oxygen via face mask
B. Placing the client in Fowler's position
C. Administering epinephrine
D. Initiating an IV infusion of 0.9% sodium chloride - ANS-A
Fowler's position to promote lung expansion after the nurse determines that the client is not
hypotensive. Epinephrine quickly to prevent circulatory shock, but oxygen first. IV NS to
maintain IV access and prevent circulatory collapse after oxygen administration.
A nurse in the emergency department is assessing a client who was admitted following a
traumatic brain injury (TBI). Which of the following findings should the nurse identify as an
indication of increased ICP?
A. Ecchymosis around both eyes
B. Asymmetric pupils
C. Hypotension
D. Leaking cerebral spinal fluid (CSF) from nose or ears - ANS-B
Ecchymosis and leaking CSF can indicate basilar skull fracture. HTN associated with increased
ICP.
A nurse is administering packed RBCs to a client. Which of the following assessment findings
indicates a hemolytic transfusion reaction?
A. Anorexia and jaundice
B. Bronchospasm and urticaria
C. Hypertension and bounding pulse
D. Low back pain and apprehension - ANS-D
Causes a systemic inflammatory response with manifestations of low back pain, hypotension,
tachycardia, and apprehension. Transfusion association graft versus host disease (within 14
days): thrombocytopenia, anorexia, nausea, chronic hepatitis, weight loss. Allergic transfusion
reactions (up to 24 hr): bronchospasm, urticaria (skin rash), anaphylaxis. Circulatory overload
(faster rate than client can tolerate): hypertension, restlessness, bounding pulses.
,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?
A. Dyspnea
B. Hemoptysis
C. Mucus production
D. Dysphagia - ANS-A
Thoracentesis is the removal of pleural fluid and can temporarily relieve hypoxia and thus ease
the client's breathing and improve comfort. Hemoptysis is coughing up blood and is common
with advanced lung cancer. Thick muscus and sputum are likely in a client with advanced lung
cancer. Dysphagia caused by advanced lung cancer results from esophageal compression and
is not likely to improve after thoracentesis.
A nurse is assessing a client who has an endotracheal tube and is receiving mechanical
ventilation. The client is agitated and appears to be in respiratory distress. Which of the
following actions should the nurse take first?
A. Manually ventilate the client using a bag-valve device
B. Suction the client's endotracheal tube
C. Contact the respiratory therapist to check the client's ventilator
D. Obtain ABGs from the client - ANS-A
Using ABC, the nurse should provide manual ventilation to reduce the risk for injury due to
hypoxia. Should disconnect the ventilator in case it is not functioning properly and provide
oxygenation until further assessment is obtained
A nurse is assessing a client who has diabetes insidious. Which of the following findings should
the nurse expect?
A. Low urine specific gravity
B. Hypertension
C. Bounding peripheral pulses
D. Hyperglycemia - ANS-A
Expected finding is a urine specific gravity between 1.001-1.005 because of decreased water
reabsorption by the renal tubules caused by an alteration in antidiuretic hormone release or the
kidneys' responsiveness to the hormone. Hypotension, weak peripheral pulses, polydipsia, and
polyuria are expected with DI. Hyperglycemia is expected with DM.
A nurse is assessing a client who has dry age-related macular degeneration (AMD) of the left
eye. Which of the following findings should the nurse expect?
A. Purulent dischange
B. Pain with blinking
C. Gradual decrease of central vision
D. Petechiae on the surrounding skin - ANS-C
Manifestation of dry AMD. As it progresses, the client will experience a total loss of the central
visual field.
, A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority?
A. Moderate serosanguinous drainage on the dressing
B. Calcium 9.5 mg/dL
C. Temperature 38.9ºC (102ºF)
D. Decreased bowel sounds - ANS-C
Elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm,
due to an increase in metabolic rate. It can lead to seizures and coma. Moderate
serosanguinous drainage is expected. Calcium of 9.5mg/dL is within normal range, but should
monitor for hypocalcemia following a thyroidectomy. Decreased bowel sounds is expected in a
client who is postoperative due to anesthesia.
A nurse is assessing a client who is receiving head and neck radiation therapy to treat
esophageal cancer. The nurse should identify which of the following findings as an adverse
effect of this treatment?
A. The client has a productive cough
B. The client reports peripheral neuropathy
C. The client reports a dry mouth
D. The client reports diarrhea - ANS-C
Dry mouth is an adverse effect of radiation therapy to the head and neck due to the damage to
the salivary glands. The client can develop tooth decay and difficulty swallowing. The nurse
should provide alcohol-free mouth rinse.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of
the following findings should the nurse identify as a manifestation of this condition?
A. Bounding pedal pulses
B. Capillary refill less than 2 seconds
C. Pain the increases with passive movement
D. Areas of warmth on the cast - ANS-C
Manifestation of compartment syndrome. Results from a decrease in blood flow in the extremity
caused by a decrease in the muscle compartment size due to a cast that is too tight. Diminished
pulses and capillary refill greater than 2 is expected. Warmth on the cast can indicate an
infection of the underlying tissue.
A nurse is assisting with a paracentesis for a client who has ascites. Which of the following
actions should the nurse take?
A. Place the client's peritoneal fluid specimen in the refrigerator following the procedure
B. Position the client into a left lateral position for the procedure
C. Weigh the client before the procedure
D. Instruct the client to have a full bladder during the procedure - ANS-C
To monitor peritoneal fluid loss
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