ATI PN MED SURG EXAM QUESTIONS
WITH COMPLETE SOLUTIONS
A nurse is participating in a health fair for older adult clients. Which of the following
vaccines should the nurse recommend for this age group? - Answer-Herpes zoster
Rationale:
The nurse should recommend the herpes zoster vaccine for adults who are 60 years of
age and older.
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The nurse should recommend the meningococcal vaccine to college students and
military recruits who are living in shared housing.
The nurse should recommend the HPV vaccine for clients who are 9 to 26 years of age.
The nurse should recommend the MMR vaccine to clients who are 62 years of age.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan
with an IV contrast agent. Which of the following laboratory findings should the nurse
report to the provider prior to the procedures? - Answer-Creatinine 1.9 mg/dL
Rationale:
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
should report the finding to the provider before the client has a CT scan with an IV
contrast agent. This finding places the client at risk for developing contrast-induced
nephropathy.
A nurse is reinforcing teaching about home care with a client who had knee
arthroplasty. Which of the following factors should the nurse identify as an indication
that a barrier to learning might be present? - Answer-The client stops the nurse and
asks for pain medication
Rationale:
The nurse should identify that a client who is in pain will not be able to concentrate,
which can interfere with their ability to learn.
,A nurse is caring for a client who has a acute ischemic stroke 1 day ago. Which of the
following actions should the nurse take to reduce the risk for aspirations? - Answer-
Allow for 30 min of rest before meals.
Rationale:
The nurse should allow the client to rest for 30 min before meals to prevent aspiration.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is
taking dantrolene to manage muscle spasms. Which of the following interventions
should the nurse include? - Answer-Encourage the client to complete ADLs.
Rationale:
The nurse should encourage the client to complete ADLs and provide assistance as
needed. Performing self-care increases the client's independence, strength, and level of
functioning.
A nurse is reinforcing about joint protection with a clietn who has an acute exacerbation
of rheumatoid arthritis. Which of the following information should the nurse include in
the teaching? - Answer-Apply cold packs to the inflamed joints
Rationale: The nurse should instruct the client to use both warm and cold packs on
inflamed joints to decrease pain.
-----------------
The nurse should instruct the client to participate in low-impact aerobic exercises, which
will not inflame the client's joints.
The nurse should instruct the client to carry a shoulder bag, which places the stress on
larger muscles.
The nurse should instruct the client to sleep on a firm mattress to support their joints.
A nurse is caring for a client who is schedules for surgery and is experiencing anxiety.
Which of the following interventions should the nurse identify as the priority? - Answer-
Determine the client's understanding of the procedure.
Rationale: When using the nursing process, the first action the nurse should take is to
collect data from the client. Therefore, the nurse should determine the client's
understanding of the procedure to reinforce necessary teaching, which can help
manage their anxiety.
A nurse is caring for a client who reports stomatitis. Which of the following dietary
recommendations should the nurse make? - Answer-Eat soft foods.
Rationale:
,The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to
decrease irritation to the oral mucosa.
-----------------
Instruct the client to avoid seasoning foods with salt or spices that can irritate the oral
mucosa.
Instruct the client to eat foods that are high in protein and calories to increase their
caloric intake and nutrition.
Instruct the client to choose foods that are a lukewarm or cool temperature to prevent
irritation of the client's oral mucosa.
A nurse is planning to implement droplet precautions for a client who has manifestations
of pertussis. Which of teh following interventions should the nurse include when
contributing to the plan of care? - Answer-Apply a mask on the client if transport is
needed.
Raitonale:
The nurse should apply a mask to a client who has manifestations of pertussis during
transport to prevent exposure to others.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following
activities should the nurse recommend to promote sleep? - Answer-Listen to soft music
before sleeping.
Rationale:
Listening to soft music can help the client to relax and reduces environmental stressors.
A nurse is contributing to the plan of care for a client who is having difficulty eating
following a stroke. Which of the following actions should the nurse take first? - Answer-
Implement recommendation from the speech language pathologist.
Rationale:
The greatest risk to the client following a stroke is injury from aspiration. Therefore, the
first intervention the nurse should include in the plan of care is to implement
recommendations from the speech language pathologist. A speech language
pathologist can conduct a swallow study to determine the client's risk for aspiration,
provide teaching to the client regarding swallowing techniques, and recommend the
consistency of foods and liquids for the client.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has
acervical spinal cord injury. Which of the following interventions should the nurse plan to
implement first? - Answer-Determine the client's daily elimination habits.
Rationale:
, The first action the nurse should take when using the nursing process is to collect data
on the client's daily bowel elimination habits to establish a routine defecation time.
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical
bowel obstruction in the descending colon. When listening in the left upper quadrant,
the nurse should identify this sound as which of the following? - Answer-Hyperactive
bowel sounds.
Rationale:
A mechanical bowel obstruction prevents a portion or all of the bowel contents from
moving forward through the bowel. The nurse should expect to auscultate high-pitched,
hyperactive bowel sounds above the point of the intestinal obstruction as the intestines
attempt to propel the blockage forward.
A nurse is assisting with the care of a client who has a newly-inserted closed chest
tube. Which of the following findings should the nurse report to the provider? - Answer-
Chest drainage is greater than 70 mL/hr
Rationale:
The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a
complication and should be reported to the provider.
A nurse is contributing to the plan of care for a client who was admitted to the
neurological unit following a stroke 3 hr ago. Which of the following interventions should
the nurse identify as the priority? - Answer-Keep the cleint in a side-lying position.
Rationale:
The greatest risk to the client following a stroke is aspiration. The nurse should position
the client in a lateral, or side-lying, position to allow any secretions to drain out of the
mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction
equipment available in the event that any secretions are present in the oral cavity.
A nurse is contributing to the plan of care for a client who is at risk for osteoporosis.
Which of the following interventions should the nurse include to prevent bone loss? -
Answer-Encourage weight bearing exercises
Rationale:
Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone
demineralization, thus helping to prevent osteoporosis.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following instructions should the nurse include in the
teaching? - Answer-Increase fiber-rich foods.
Rationale:
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