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Exam (elaborations)

ATI EXIT EXAM MED SURG II PRACTICE QUESTIONS AND ANSWERS

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  • ATI Med Surg
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  • ATI Med Surg

ATI EXIT EXAM MED SURG II PRACTICE QUESTIONS AND ANSWERS A 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...

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  • October 31, 2024
  • 79
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • ATI Med Surg
  • ATI Med Surg
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ATI EXIT EXAM MED SURG II PRACTICE

QUESTIONS AND ANSWERS


A 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. - ANSWER✔✔-B. Assist the

client to a supine position.


C. Administer an opioid medication.


D. Encourage the client to increase fluid intake.


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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 - ANSWER✔✔-B. Infection




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, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED

FIRST PUBLISH OCTOBER 2024




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 - ANSWER✔✔-B. 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.




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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." - ANSWER✔✔-A. "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


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