1. A nurse is providing postoperative teach- Flex the foot every hour when
ing for a client who had a total knee awake.
arthroplasty. Which of the following in- Rationale: The nurse should in-
structions should the nurse include? struct 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 Bubbling in the water seal
has a pneumothorax and a closed-chest chamber has ceased.
drainage system. Which of the following Rationale: Bubbling in the water
findings is an indication of lung re-expan- seal chamber ceases when the
sion? lung re-expands.
3. A nurse is reviewing the medical record of INR 2.5
a client who is taking warfarin for chronic Rationale: Clients receive war-
atrial fibrillation. Which of the following farin therapy to decrease the
values should the nurse identify as a de- risk of stroke, myocardial in-
sired outcome for this therapy? farction (MI), or pulmonary em-
boli (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 anticoagula-
tion). 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 teach- Change position every hour
ing to a client who has a stage 1 pressure Rationale: Changing position
injury on the greater trochanter of his left every 1 to 2 hr decreases pres-
hip. Which of the following instructions sure on bony prominences. The
should the nurse include in the teaching? nurse should also instruct the
client to limit the angle of the
hips when in a lateral position to
, ATI RN ADULT MEDICAL SURGICAL EXAM
no more than 30°. This position-
ing prevents direct pressure on
the trochanter.
5. A nurse is assessing a client following the Restlessness
completion of hemodialysis. Which of the Rationale: Using the urgent vs.
following findings is the nurse's priority nonurgent approach to client
to report to the provider? care, the nurse should deter-
mine that the priority finding to
report to the provider is rest-
lessness, which can be an indi-
cation the client is experiencing
disequilibrium syndrome. Dise-
quilibrium syndrome is caused
by the rapid removal of elec-
trolytes from the client's blood
and can lead to dysrhythmias
or seizures. Other manifesta-
tions include nausea, vomiting,
fatigue, and headache.
6. A nurse is caring for a client who is 8 hr Scan the bladder with a portable
postoperative following a total hip arthro- ultrasound.
plasty. The client is unable to void on the Rationale: The first action the
bedpan. Which of the following actions nurse should take using the
should the nurse take first? 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 Hypertension
presentation for a group of African Amer- Rationale: When using the safe-
ican clients at a community center. Which ty/risk reduction approach to
of the following disorders presents the client care, the nurse should de-
greatest risk to this group of clients? termine that the disorder with
the greatest risk for this group
of clients is hypertension. The
prevalence of hypertension is
, ATI RN ADULT MEDICAL SURGICAL EXAM
highest among African Ameri-
can clients, followed by Cau-
casian clients, and then Hispan-
ic clients.
8. A nurse is caring for a client who has Glucose 272 mg/dL
DKA. Which of the following findings Rationale: A glucose reading
should indicate to the nurse that the less than 300 mg/dL indicates
client's condition is improving? improvement in the client's sta-
tus.
9. A nurse is caring for a client following Stridor
extubation of an endotracheal tube 10 Rationale: Using the urgent vs.
min. ago. Which of the following findings nonurgent approach to client
should the nurse report to the provider care, the nurse should deter-
immediately? mine 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 imme-
diately and implement an inter-
vention.
10. A nurse is caring for a client who had a The client reports back pain
nephrostomy tube inserted 112 hr ago. Rationale: The nurse should no-
Which of the following findings should tify the provider if the client re-
the nurse report to the provider? ports back pain, which can indi-
cate that the nephrostomy tube
is dislodged or clogged.
11. A nurse is admitting a client who has Airborne
active TB. Which of the following types Rationale: Airborne precautions
of transmission precautions should the are required for clients who have
nurse initiate? infections due to micro-organ-
isms that can remain suspend-
ed in air for lengthy periods
of time, such as tuberculosis,
measles, varicella, and dissem-
inated varicella zoster.
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