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Med surg exam 3 ATI practice exam 2024/2025 questions w/ rationales & Verified Solutions.
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Med surg exam 3 ATI practice exam 2024/2025 questions w/ rationales & Verified Solutions.
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Med surg exam 3 ATI practice questions w/rationales
A home health nurse is teaching an older adult client who just had cataract surgery. Which of
the following instruction should the nurse include? - ANS - Keep your head up and straight
Rationale: keeping the head straight and avoiding looking down prevents increasing intraocular
pressure
\A nurse at a community health clinic is caring for a client who reports a headache and stiff
neck. Which of the following actions should the nurse take first? - ANS - Evaluate the client's
neurological status
Rationale: manifestations of a headache and stiff neck (nuchal rigidity) or indication that the
client might have meningitis. The greatest risk to the client is injury from increased intracranial
pressure, which can lead to brain herniation and death. Therefore, the nurse should complete a
neurological assessment as a baseline. If the client does have meningitis, neurological checks
should be completed every 2 to 4 hours.
\A nurse at a rehabilitation center is planning care for a client who had a left hemispheric
cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse
include in the client's rehabilitation program? - ANS - Establish the ability to communicate
effectively
Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in
damaged brain tissue. The left hemisphere is usually dominant for language. Because this client
had a left side CVA, the nurse should anticipate the client will have some degree of aphasia and
will require speech therapy to establish communication.
\A nurse at an outpatient surgery center is providing discharge teaching to a client and his
spouse following surgical removal of a cataract. Which of the following should the nurse include
in the teaching? - ANS - the client should wear dark glasses while outdoors
Rationale: the nurse instruct the client and his spouse that he should wear dark glasses, went
outside or in bright light until pupil reaction returns
\A nurse caring for a client who had a right sided stroke and is exhibiting homonymous
hemianopsia when eating. Which of the following action should the nurse take? - ANS - Remind
the client to look for food on the left side of the tray
Rationale: the nurse's action to remind the client to look for food on the left side of the tray will
train the client to scan the tray by moving his head and eyes, which will help to resolve the
problem of homonymous hemianopsia.
, \A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care
provider for suspicion of cataracts. The nurse should expect the client to report? - ANS - having
a decreased ability to perceive colors
Rationale: symptoms of cataracts include painless blurred vision and a decrease in the ability to
perceive colors
\A nurse in the emergency department is caring for a client following an automobile crash in
which the client was unrestrained and thrown from the vehicle. When assessing the client, the
nurse observes clear fluid draining from the client's nose. Which of the following intervention
should the nurse take? - ANS - Allow the drainage to drop onto a sterile gauze pad
Rationale: the nurse should allow the drainage to drip onto a sterile gauze pad in order to
assess for the presence of cerebrospinal fluid. This intervention allows for the collection of data,
without increasing the risk for further injury.
\A nurse in the emergency department is caring for a client who has an epidural hematoma
following a motor vehicle crash. Which of the following is an expected finding for this client? -
ANS - Alternating periods of alertness and unconsciousness
Rationale: alternating periods of alertness and unconsciousness is a common manifestation of
an epidural hematoma
\A nurse in the emergency department is caring for a client who is myasthenia gravis and is in
crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic
crisis? - ANS - Developing a respiratory infection
Rationale: the most common triggers of myasthenic crisis are respiratory infection, not taking, or
taking too little, of the prescribed medication, surgery, and high environmental temperatures
\A nurse in the emergency department is monitoring a client who has a cervical spinal cord
injury from a fall. The nurse should monitor the client for which of the following complications? -
ANS - • hypotension- lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mmHg or above to adequately perfuse the spinal
cord. •absence of bowel sounds- spinal shock leads to decreased peristalsis, which could cause
the client to develop a paralytic ileus
• weakened gag reflex- the nurse should monitor the client for difficulty swallowing, or coughing
and drooling noted with oral intake
\A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse
closely monitor the client for increased intracranial pressure as indicated by which of the
following findings? - ANS - Widened pulse pressure
Rationale: a widened pulse pressure is a manifestation of increased ICP. Other manifestations
include bradycardia, vomiting and decreased LOC
\A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of
the following findings should the nurse report to the provider? - ANS - Small drops of clear fluid
in left ear
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