ATI Proctored Exam Medical Surgical Form A

1. A nurse is preparing to administer thrombolytic therapy to a client who had an

ischemic stroke. Which of the following is an appropriate nursing action?

-Start the therapy within 8 hrs. (within 6 hrs.)

-Insert an indwelling urinary catheter after therapy begins

-Monitor blood pressure every 30 minutes during infusion.

-Elevate the head of the bed between 25 and 30 degrees (to reduce ICP & promote venous

drainage, ATI page 89)

2. A nurse is teaching a client about the use of an incentive spirometer. Which of the following

instructions should the nurse include in the teaching?

-Place hands on the upper abdomen during inhalation.

-Exhale slowly through pursed lips.

-Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)

-Position the mouthpiece 2.5 cm (1 in) from the mouth.

3. A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which

of the following findings should the nurse report to the surgeon?

-Heart rate 90/mm

-Hgb 8.2 g/dL

-Gastric ph of 3.0

-Absent bowel sounds

Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply

total obstruction. QSEN: Safety (Book page 1143)

4. A nurse is caring for a client who has diabetes insipidus. Which of the following medications

should the nurse plan to administer?

-Regular Insulin

-Furosemide

-Desmopressin

-Lithium Carbonate

Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or

by nasal spray.

Management focuses on controlling symptoms with drug therapy.

-The most preferred drug is desmopressin acetate (DDAVP), a synthetic form of

vasopressin given orally, as a sublingual “melt,” or intranasally in a metered spray. The

frequency of dosing varies with patient responses. Teach patients that each metered spray

delivers 10 mcg and those with mild DI may need only one or two doses in 24 hours.

-For more severe DI, one or two metered doses two or three times daily may be needed.

5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several

times daily for 3 years. Which of the following test should the nurse monitor?

Stool occult blood

-Urine for white blood cells

-Fasting blood glucose

-Serum calcium

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Assess for drug-related blood loss such as that caused by NSAIDs by checking the stool for

gross or occult blood. Older white women are the most likely to experience GI bleeding as

a result of taking these medications. (Book page 324)

6. A nurse in the emergency department is assessing a client. Which of the following actions

should the nurse take first? (Click on the “Exhibit” button for additional information about the

client. There are three tabs that contain separate categories of data.)

-Obtain a sputum sample for culture.

-Prepare the client for a chest x-ray.

-Initiate airborne precautions (question sounds like a respiratory issue)

-Administer ondansetron.

7. A nurse is contacting the provider of a client who has cancer and is experiencing

breakthrough pain. Which of the following prescriptions should the nurse anticipate?

-Intravenous dexamethasone

-Transmucosal fentanyl

-Oral acetaminophen- not strong enough

-Intramuscular meperidine

Fentanyl is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has a fast onset

and short duration of action. It is recommended opioid for patients with end-organ failure

because it has no clinically relevant metabolites. It also produces fewer hemodynamic adverse

effects than other opioids; therefore, it is often preferred in patients who are hemodynamically

unstable such as the critically ill. (Book page 59)

8. A nurse is admitting a client who reports chest pain and has been placed on a telemetry

monitor. Which of the following should the nurse analyze to determine whether the client

is experiencing a myocardial infarction?

-QRS duration

-ST segment

-T-wave

PR interval

Examine the ST segment. The normal ST segment begins at the isoelectric line. ST elevation

or depression is significant if displacement is 1 mm (one small box) or more above or below

the line and is seen in two or more leads. ST elevation may indicate problems such as

myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with

hypokalemia, myocardial infarction, or ventricular hypertrophy. (Book page 670)

9. A nurse is teaching a client who has ovarian cancer about skin care following

radiation treatment. Which of the following instructions should the nurse include?

-Apply over the counter moisturizer to the radiation site

-Cover the radiation site loosely with a gauze wrap before dressing

-Use a soft washcloth to clean the area around the radiation site

-Pat the skin on the radiation site to dry it. (Book page 390)

Skin Protection During Radiation Therapy

• Wash the irradiated area gently each day with either water or a mild soap and water

as prescribed by your radiation therapy team.

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• Use your hand rather than a washcloth when cleansing the therapy site to be gentler.

• Rinse soap thoroughly from your skin.

• If ink or dye markings are present to identify exactly where the beam of radiation is to be

focused, take care not to remove them.

• Dry the irradiated area with patting rather than rubbing motions; use a clean, soft towel or

cloth.

• Use only powders, ointments, lotions, or creams that are prescribed by the radiation oncology

department on your skin at the radiation site.

• Wear soft clothing over the skin at the radiation site.

• Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at

the radiation site.

• Avoid exposure of the irradiated area to the sun:

• Protect this area by wearing clothing over it.

• Try to go outdoors in the early morning or evening to avoid the more intense sun rays.

• When outdoors, stay under awnings, umbrellas, and other forms of shade during the times when

the sun's rays are most intense (10 AM to 7 PM).

• Avoid heat exposure.

10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that

the client has bounding peripheral pulses, hypertension, and distended jugular veins. The

nurse should anticipate administering which of the following prescribed medications?

Acetaminophen

-Furosemide (this patient has fluid overload from the transfusion)

Diphenhydramine

Pantoprazole

11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of

hypomagnesemia. Which of the following findings indicates effectiveness of the

medication?

-Lungs clear

-Hypoactive bowel sounds- Reduced motility, anorexia, nausea, constipation, and abdominal

distention are common. A paralytic ileus may occur when hypomagnesemia is severe.

-Blood pressure 90/50 mm Hg-hypomagnesemia causes hypertension, but this is too low,

abnormal

-Apical pulse 82/min

One aspect of the conduction problems is that, when serum magnesium levels are low,

intracellular potassium levels are also low. This changes the resting membrane potential in

cardiac muscle cells, slowing normal conduction and triggering ectopic beats.

12. A nurse is preparing a client for a lumbar puncture. Which of the following images indicates

the position the nurse should assist the client into for this procedure?

- “Cannonball position on the side” picture #4 (ATI page 20)

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