ATI MEDSURG PROCTORED EXAM RETAKE GUIDE 90 QUESTIONS WITH 100% CORRECT ANSWERS

1. A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the

following instructions should the nurse include?

a. Flex the foot every hour when awake.

b. Place a pillow under the knee when lying in bed.

c. Lower the leg when sitting in a chair.

d. Ensure the leg is abducted when resting in bed.

The nurse should instruct the client to flex the foot every hour to reduce the risk for

thromboembolism and promote venous return.

2. 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?

a. The chest tube is draining serosanguineous fluid at 65 mL/hr.

b. The client tolerates gentle milking of the tubing.

c. Bubbling in the water seal chamber has ceased.

d. There is tidaling in the water seal chamber.

Bubbling in the water seal chamber ceases when the lung re-expands.

3. 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?

a. INR 1

b. INR 2.5

c. aPTT 45 seconds

d. aPTT 90 seconds

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.

4. 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?

a. Clean the wound daily with an antiseptic.

b. Use a donut-shaped pillow when sitting in a chair.

c. Change position every hour.

d. Massage the area two times daily.

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.

5. 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?

a. Temperature 37.2° C (99° F)

b. Blood pressure 100/70 mm Hg

c. Weight loss

d. Restlessness

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.

6. 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?

a. Document the client's intake and output.

b. Scan the bladder with a portable ultrasound.

c. Pour warm water over the client's perineum.

d. Perform a straight catheterization.

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.

7. 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?

a. Multiple sclerosis

b. Skin cancer

c. Urolithiasis

d. Hypertension

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.

8. 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?

a. Potassium 3.5 mEq/L

b. pH 7.28

c. Glucose 272 mg/dL

d. HCO3- 14 mEq/L

A glucose reading less than 300 mg/dL indicates improvement in the client's status.

9. A nurse is caring for a client following extubation of an endotracheal tube 10 minutes ago. Which of the

following findings should the nurse report to the provider immediately?

a. Stridor

b. Oral secretions

c. Hoarseness

d. Sore throat

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.