ATI Med-Surg Proctored Exam 2020/2021 (Complete

Version) Latest Updated Solution

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the

following findings should indicate to the nurse that the therapy has been effective?

Hemoglobin 14.9 g/dL

The nurse should identify that packed RBCs are administered to clients who have a

decreased level of hemoglobin or hematocrit. This hemoglobin level is within the

expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females,

indicating the therapy has been effective.

A nurse working in an emergency department is triaging four clients. Which of the following

clients should the nurse recommend for treatment first?

A middle adult client who has unstable vital signs.

Using the stable vs unstable approach to client care, the nurse should recommend

priority treatment for the client who has unstable vital signs because this client requires

immediate treatment to reduce the risk of further injury or possible death.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should

the nurse delegate to the CNA?

Measure the client’s daily weight

It is within the CNAs range of function to measure a client’s daily weight, so the nurse

should delegate this task to them.

A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a

client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse

should administer?

18 g

A nurse is conduction a physical examination for an adolescent and is assessing the range of

motion of the legs. Which of the following images indicates the adolescent is abducting the hip

joint?

In the correct image, the adolescent is abduction the hip joint by moving the leg away

from the midline of the body.

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should

the nurse expect?

Tremors

Tremors are a manifestation of hyperthyroidism, along with tachycardia,

diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following

findings should the nurse expect?

Nuchal rigidity

This is a manifestation of bacterial meningitis.

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A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse

take?

Auscultate the apical pulse at least 1 min.

The nurse should auscultate the apical pulse to obtain an accurate assessment of heart

rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of

the rapid rate and the transmission of respiratory sounds.

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The

nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure.

It is important for the nurse to remind the client to avoid coughing and to lie still during a

thoracentesis to avoid puncturing the pleura.

A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should

identify which of the following findings as a potential indication of child sexual abuse?

The child exhibits discomfort while walking.

The nurse should identify this finding as a potential indication of child sexual abuse.

A nurse is preparing to teach about dietary management to a client who has Crohn’s disease

and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client

to decrease in their diet?

Fiber

The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and

inflammation.

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM)

machine following a total knee arthroplasty. Which of the following actions should the

nurse take?

Turn off the CPM machine during mealtime.

This promotes client comfort and dietary intake.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites

should the nurse select when initiating the IV for the client?

Radial vein of the inner arm.

This site will have adequate subcutaneous tissue.

A nurse is developing a client education program about osteoporosis for older adult clients. The

nurse should include which of the following variables as a risk factor for osteoporosis?

Sedentary lifestyle.

This is a risk factor for osteoporosis. The nurse should encourage older adult clients to

engage in weight-bearing exercises because they will promote bone health by increasing

calcium and phosphorus levels.

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A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and

extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions

When using the urgent vs nonurgent approach to client care, the nurse should determine

that the priority action is to initiate transmission-based precautions for the child. The

child most likely has varicella. Therefore, the nurse should isolate the child to prevent the

spread of the infection.

A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which

of the following actions should the nurse take first?

Change the position of the client.

When providing client care, the nurse should use the least restrictive intervention first.

Therefore, the nurse should reposition the client to remove any kinks in the tube, which

can lead to clogging. If this method is unsuccessful, the nurse should attempt to flush or

aspirate the client’s tube to remove the clog.

A home health care nurse is developing a teaching plan for a client who has a new

ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full.

The ileostomy pouch should be emptied when it is one-third to one-half full to prevent

stool leakage and skin irritation.

A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and

received hemodialysis 24 yr ago. Which of the following lab values should the nurse report to

the provider?

Sodium 148 mEq/L

The nurse should report this sodium level because it is above the expected reference

range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease

often retain sodium and require sodium-restricted diets.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to a

CNA?

Arrange the lunch tray for a client who has a hip fracture.

Assisting a client with meals is within the range of function of the CNA.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse

take?

Instruct the client to void.

The nurse should instruct the client to void prior to the procedure because an empty

bladder decreases the risk of a bladder puncture and minimizes the client’s discomfort

during the procedure.

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