ATI MED-SURG FOR 2024 EXAM (REAL)

ATI MED-SURG ATI MED-SURG ATI MED-SURG ATI MED-SURG ATI MED-SURG ATI MED-SURG

QUESTIONS AND CORRECT 

ANSWERS PLUS  

RATIONALES (VERIFIED 

ANSWERS  

)|AGRADE  

ATI MED-SURG  

1. A nurse is reinforcing teaching with a client who has HIV and is being discharged

to home. Which of the following instructions should the nurse include in

the teaching?  

1) Take temperature once a day. 

Answer Rationale:  

The nurse should reinforce to the client to take his temperature once a daily to

identify if a temperature is present due to the client’s altered immune system.  

INCORRECT 

2) Wash the armpits and genitals with a gentle cleanser daily. 

Answer Rationale: 

The nurse should instruct the client to use an antimicrobial cleanser to wash his 

armpits and genitals twice daily.  

INCORRECT 

3) Change the litter boxes while wearing gloves. Answer Rationale:  

The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life

threatening to a client who has HIV.  

INCORRECT 

4) Wash dishes in warm water.  

Answer Rationale: 

The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.  

2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious 

and tenacious secretions. Which of the following is an acceptable method for the nurse to

use to thin this client's secretions?  

1) Provide humidified oxygen. Answer Rationale: 

Increasing fluid intake as tolerated and providing adequate humidification can help thin secretions 

safely.  

INCORRECT 

2) Perform chest physiotherapy prior to suctioning. Answer Rationale:  

Performing chest physiotherapy mobilizes secretions but does not thin them.  

INCORRECT 

3) Prelubricate the suction catheter tip with sterile saline when 

suctioning the airway.  

Answer Rationale:  

Prelubricating the suction catheter tip with sterile saline helps to ease the insertion of the

catheter, producing less trauma. However, it has no effect on the tenacity of the client's

secretions.  

INCORRECT 

4) Hyperventilate the client with 100% oxygen before suctioning the 

1) 

airway.  

3) Thick, red-colored urine Answer

Rationale:  

Answer Rationale: 

Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on the 

Answer Rationale: 

The nurse should reinforce that exercise should follow a meal. Exercising first thing in the morning 

The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and

should be reported to the provider immediately.  

tenacity of the client's secretions.  

on an empty stomach places the client at risk for hypoglycemia.  

INCORRECT 

3) "I should avoid injecting insulin into my thigh if I am going to go running." 

INCORRECT 

4) Pain level of 4 on a 0 to 10 rating scale 

1) 

2) 3) 

3. Following admission, a client with a vascular occlusion of the right lower extremity calls

the nurse and reports difficulty sleeping because of cold feet. Which of the following

nursing actions should the nurse take to promote the client's comfort?  

Answer Rationale: 

The nurse should reinforce that the client should avoid injecting insulin into an area that will soon 

Answer Rationale: 

The nurse should assess for and treat postoperative pain which is an expected finding in the 

be exercised to avoid increasing the absorption rate of the insulin. 

4) "I will not exercise if my urine is positive for ketones." Answer Rationale:  

postoperative client; however it is not the priority finding to report. Specific pain, such as bladder

spasms, may indicate complications however and should be reported to the provider.  

INCORRECT 

1) Rub the client's feet briskly for several minutes. Answer 

The nurse should reinforce that exercise should be avoided if ketones are present in the urine as

this indicates an elevated blood glucose level or ketoacidosis.  

5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a

prescription for a hypothermia blanket. The nurse should monitor the client for which of

the following adverse effects of the hypothermia blanket?  

Rationale: 

Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the lower 

extremities is a contraindication for leg massage. 

2) Obtain a pair of slipper socks for the client. Answer Rationale:  

7. A nurse notes a small section of bowel protruding from the abdominal incision of a client

who is postoperative. After calling for assistance, which of the following actions should the

nurse take first?  

1) Shivering 

Answer Rationale:  

Slipper socks with nonskid soles will help provide warmth and increase the client's level of comfort.  

The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can

cause the client’s temperature to increase.  

INCORRECT 

3) Increase the client's oral fluid intake. Answer Rationale:  

1) Cover the client's wound with a moist, sterile dressing. Answer

Rationale:  

INCORRECT 

2) Infection Answer 

Increasing the client's fluid intake will not increase circulation to an area an occlusion impairs.  

According to evidence-based practice, the nurse's first action should be to cover the wound with

a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the tissue moist.  

Rationale: 

Infection is not a complication of the hypothermia blanket therapy. A manifestation of infection 

INCORRECT 

4) Place a moist heating pad under the client's feet. Answer 

INCORRECT 

2) Have the client lie supine with knees flexed. Answer Rationale:  

is hyperthermia.  

Rationale: 

Impaired arterial or venous circulation to a lower extremity is a contraindication for applying a 

The nurse should have the client lie supine with knees flexed to promote adequate circulation

to the vital organs. However, evidence-based practice indicates that this is not the first action

the nurse should take.  

INCORRECT 

3) Burns  

heating pad.  

Answer Rationale: 

Burns are associated with the improper use of heating pads, not hypothermia blankets.  

INCORRECT 

3) Check the client's vital signs. Answer Rationale:  

4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection

of the prostate (TURP). Which of the following is the priority finding for the nurse report to

the provider?  

INCORRECT 

4) Hypervolemia Answer 

The nurse should check the client’s vital signs because the client is at risk for shock following

wound evisceration. However, evidence-based practice indicates that this is not the first action

the nurse should take.  

Rationale: 

Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk 

INCORRECT 

 Emesis of 100 mL Answer 

INCORRECT 

4) Inform the client about the need to return to surgery. Answer 

associated with hyperthermia due to fluid loss.  

Rationale: 

The nurse should recognize postoperative nausea is a complication related to the administration 

Rationale: 

The nurse should inform the client about the need to return to emergency surgery to preserve 

of anesthesia and should treat the nausea with anti-emetics and provide supportive measures;

however, it is not the priority finding.  

6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes

mellitus. Which of the following statements by the client indicates an understanding of

the teaching?  

the bowel and prevent complications. However, evidence-based practice indicates that this is

not the first action the nurse should take.  

INCORRECT 

2) Oral temperature of 37.5° C (99.5° F) Answer 

INCORRECT 

1) "I will carry a complex carbohydrate snack with me when I exercise." Answer Rationale:  

Rationale: 

The nurse should monitor a client who develops a fever and encourage deep breathing, coughing, 

8. A nurse is collecting data from a client who has alcohol use disorder and is experiencing

metabolic acidosis. Which of the following manifestations should the nurse expect?  

The nurse should reinforce that the client should carry a simple carbohydrate such as hard candy

or glucose tablets for use during exercise if the client becomes hypoglycemic.  

and fluid intake (if permitted); however, it is not the priority finding to report. The increase in

temperature is likely due to decreased respiratory effort related to the use of anesthesia and

should clear with pulmonary hygiene.  

INCORRECT  

INCORRECT 

2) "I should exercise first thing in the morning before eating breakfast."  

The nurse should instruct the client that flashes of light indicates a complication of cataract

extraction, and should be reported to the provider.  

 Cool, clammy skin Answer

Rationale:  

10. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg

daily. The client refuses breakfast and reports nausea. Which of the following actions

should the nurse take first?  

The nurse should expect to find warm, flushed skin in a client who is experiencing metabolic

acidosis.  

INCORRECT 

1) Suggest that the client rests before eating 

 Hyperventilation Answer

Rationale:  

the meal. Answer Rationale: 

The nurse should encourage frequent rest periods for the client who has heart failure, as dyspnea 

The nurse should expect to find hyperventilation in a client who is experiencing metabolic

acidosis. The system attempts to compensate or return the pH to normal by increasing the rate

and depth of respirations.  

and fluid overload increases the workload to consume adequate nutrition; however, another action

is the priority.  

INCORRECT 

3) Increased blood 

INCORRECT 

2) Request a dietary consult. Answer Rationale:  

pressure Answer

Rationale:  

The nurse should consider obtaining a dietary consult for the client who has heart failure to

provide nutritional evaluation and counseling; however, another action is the priority.  

The nurse should expect to find hypotension in a client who is experiencing metabolic acidosis.  

3) Check the client's vital signs. Answer

Rationale:  

INCORRECT 

4) Bradycardia Answer 

When using the airway, breathing, circulation approach to client care, the nurse should place the

priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other

manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision.  

Rationale: 

The nurse should expect to find tachycardia in a client who is experiencing metabolic acidosis.  

INCORRECT 

4) Request an order for an antiemetic. Answer 

Rationale: 

The nurse should request antiemetics for the client who is experiencing nausea in order to maintain 

9. A nurse is reinforcing discharge teaching with a client following a cataract extraction.

Which of the following should the nurse include in the teaching?  

client comfort and nutritional intake; however, another action is the priority. 

11. A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The 

1) Avoid bending at the waist. Answer Rationale: 

The nurse should reinforce that the client should avoid bending at the waist as this increases 

nurse suspects the client's wound is infected because the drainage from the dressing is

yellow and thick. Which of the following findings should the nurse report as the type of

drainage found?  

intraocular pressure; the client should be instructed to flex the knees and crouch instead.  

INCORRECT 

2) Remove the eye shield at bedtime.  

INCORRECT 

1) Sanguineous  

Answer Rationale: 

The client should be instructed to use an eye shield when retiring for the night to protect the 

Answer Rationale: 

Sanguineous indicates fresh bleeding.  

eye from accidental injury, such as rubbing that may occur when the client is asleep.  

INCORRECT 

2) Serous  

INCORRECT 

3) Limit the use of laxatives if constipated. Answer 

Answer Rationale: 

Serous describes clear, watery plasma.  

Rationale: 

The client should be encouraged to use laxatives in the event of constipation to avoid straining 

while attempting to have a bowel movement. Straining increases intraocular pressure and can

cause damage to the surgical site.  

INCORRECT 

 Serosanguineous Answer 

INCORRECT 

4) Seeing flashes of light is an expected finding following 

Rationale: 

Serosanguineous describes watery drainage that has some blood in it.  

extraction. Answer Rationale:  

4) Purulent 

Answer Rationale:  

Purulent describes drainage that is thick yellow, green, or brown in color.  

12. A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To

prevent postoperative complications which of the following actions should be reinforced

during the teaching?  

1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. 

Answer Rationale:  

The nurse should administer analgesics prior to initiating any exercise program for the client who

has had joint arthroplasty. It is important that analgesics are administered in time for the

medication to work before the start of the exercise program to ensure discomfort is minimized.  

INCORRECT 

2) Place the client’s affected leg into the CPM machine with the machine in the flexed 

position. 

Answer Rationale:  

The nurse should place the client’s leg in the CPM machine while the machine is in the extended

position to allow for proper fit and comfort.  

INCORRECT 

3) Place the client into a high Fowler’s position when initiating the CPM exercises.  

Answer Rationale: 

The nurse should limit the elevation of the client’s head of the bed to no more than 20 degrees 

while the client is using the CPM machine to avoid extreme flexion of the hip and patient

discomfort.  

INCORRECT 

4) Align the joints of the CPM machine with the knee gatch in the client’s bed. Answer 

Rationale: 

The nurse should align the joints of the CPM machine with the client’s knee joint to ensure safe 

operation of the unit and prevent injury to the client.  

13. A nurse is collecting data from a client who has emphysema. Which of the following findings

should the nurse expect? (Select all that apply.)  

1) Dyspnea 

2) Barrel chest 

3) Clubbing of the fingers 

4) Shallow respirations  

INCORRECT