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ATI EXIT EXAM MED SURG II 2024/2025 (100% verified)
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ATI EXIT EXAM MED SURG II 2024/2025 (100% verified)
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ATI EXIT EXAM MED SURG IIA nurse is caring for a client who is postprocedure following a lumbar puncture and reports a
throbbing headache when sitting upright. Which of the following actions should the nurse
take? (Select all that apply).
A. Use the Glasgow Coma Scale when assessing the client.
B. Assist the client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
E. Instruct the client to perform deep breathing and coughing exercises. - ANSB. Assist the
client to a supine position.
C. Administer an opioid medication.
D. Encourage the client to increase fluid intake.
Rationale: (B) The nurse should assist the client to a supine position, which can relieve a
headache following a lumbar puncture
(C) The nurse should administer an opioid medication for a client's report of headache pain.
(D) The nurse should encourage increased fluid intake to maintain a positive fluid balance,
which can relieve a headache following a lumbar puncture
A nurse is caring for a client who experienced a traumatic head injury and has an
intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the
client for which of the following complications related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension - ANSB. Infection
Rationale: The nurse should monitor a client who has a ventriculostomy for infection, which
is a complication. The nurse should use strict asepsis to avoid this life-threatening condition,
which can result in meningitis.
A nurse is assessing a client for changes in the level of consciousness using the Glasgow
Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and
moves his extremities when pain is applied. Which of the following GCS scores should the
nurse document?
A. E2 + V3 + M5 = 10
B. E3 + V4 + M4 = 11
C. E4 + V5 + M6 = 15
D. E2 + V2 + M4 = 8 - ANSB. E3 + V4 + M4 = 11
,Rationale: The client's score is calculated correctly, indicating moderate head injury. E3
represents opening eyes secondary to voice stimulation, V4 represents the verbal
conversation that is incoherent and disoriented and M4 represents motor response as
general withdrawal to pain.
A nurse is developing a plan of care for a client who is scheduled for cerebral angiography
with contrast dye. Which of the following statements by the client should the nurse report to
the provider? (Select all that apply).
A. "I think I might be pregnant."
B. "I take warfarin."
C. "I take antihypertensive medication."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning." - ANSA. "I think I might be pregnant."
B. "I take warfarin."
D. "I am allergic to shrimp."
E. "I ate a light breakfast this morning."
Rationale: (A) The nurse should report the client's statement of possible pregnancy to the
provider because the contrast dye can place the fetus at risk. (B) The nurse should report
that the client is taking warfarin to the provider due to the potential for bleeding following
angiography (D) The nurse should report a clients report of allergy to shrimp, which is a
shellfish, to the provider due to a potential allergic reaction to the contrast dye (E) The nurse
should report a client's intake of food to the provider since the client should remain NPO for
4 to 6 hr. prior to the procedure.
A nurse is providing education to a client who is to undergo an electroencephalogram (EEG)
the next day. Which of the following information should the nurse include in the teaching?
A. "Do not wash your hair the morning of the procedure."
B. "Try to stay away most of the night prior to the procedure."
C. "The procedure will take approximately 15 minutes."
D. "You will need to lie flat for 4 hours after the procedure." - ANSB. "Try to stay away most
of the night prior to the procedure."
Rationale: The nurse should teach the client to remain awake most of the night to provide
cranial stress and increase the possibility of abnormal electrical activity.
A nurse is assessing the pain level of a client who came to the emergency department
reporting severe abdominal pain. The nurse asks the client whether he has nausea and has
been vomiting. The nurse is assessing which of the following components of a pain
assessment?
A. Presence of associated manifestations.
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors - ANSA. Presence of associated manifestations.
, Rationale: Nausea and vomiting are common manifestations clients have when they are in
pain
A nurse is assessing a client who is reporting pain despite analgesia. Which of the following
actions should the nurse take to assess the intensity of the client's pain?
A. Ask the client what precipitates his pain.
B. Question the client about the location of his pain.
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the sensation of his pain. - ANSC. Offer the client a
pain scale to measure his pain
Rationale: The nurse should use a pain scale to help the client measure the amount of pain
he has and its intensity.
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia
(PCA) infusion device after abdominal surgery. Which of the following client statements
indicates that the client understands how to use the device?
A. "I'll wait to use the device until it's absolutely necessary."
B. "I'll be careful about pushing the button to I don't get an overdose."
C. "I should tell the nurse if the pain doesn't stop after I use this device."
D. "I will ask my son to push the dose button when I am sleeping." - ANSC. "I should tell the
nurse if the pain doesn't stop after I use this device."
Rationale: The nurse should identify that PCA is a method of delivering pain medication
through an electronic infusion device that allows the client to self-administer pain medication
on an as-needed basis. If the client is not achieving adequate pain control, he should let the
nurse know so that she can initiate a reevaluation of the client's pain management plan.
A nurse is discussing pain assessment with a newly licensed nurse. Which of the following
information should the nurse include?
A. Most clients exaggerate their level of pain.
B. Pain must have an identifiable source to justify the use of opioids.
C. Objective data are essential in assessing pain.
D. Pain is whatever the client says it is. - ANSD. Pain is whatever the client says it is.
Rationale: The nurse should identify that pain is a subjective experience, and the client is the
best source of information about it.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the following
findings should the nurse identify as adverse effects of opioid analgesics? (Select all that
apply).
A. Urinary incontinence.
B. Diarrhea
C. Bradypnea
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