ATI PN Medical Surgical

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Free ATI PN Medical Surgical Questions

1.

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching?

  • "I should put lotion between my toes every day to prevent dryness and cracking."
  • "I should apply a heating pad to my feet every night to help with circulation."
  • "I should use my wrist to test the temperature of the water before bathing."
  • "I should round the corners of my toenails with a nail file to prevent ingrown nails."

Explanation

Explanation
c) "I should use my wrist to test the temperature of the water before bathing."
Clients with diabetes often experience peripheral neuropathy, which decreases sensation in the hands and feet. Because of this, they are unable to reliably detect excessively hot water and are at higher risk for burns. Using the wrist, which has better temperature sensitivity, allows the client to accurately assess water temperature and avoid injury. This method is a key safety practice in diabetic foot and skin care and demonstrates correct understanding of how to prevent burns and skin breakdown.
Correct Answer Is:
c) "I should use my wrist to test the temperature of the water before bathing."
2.

A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make?

  • "I'm sure any partner will understand that you have no control over this."
  • "There are other ways to express intimacy besides intercourse."
  • "You should focus on recovering from your cancer right now."
  • "The removal of a single testicle will not prevent you from having an erection."

Explanation

Explanation
An orchiectomy involving only one testicle does not impair the ability to achieve an erection because erectile function is controlled by vascular and neurological mechanisms, not by the number of testicles present. The remaining testicle continues to produce adequate testosterone, supporting sexual function and libido. Providing this factual reassurance directly addresses the client’s expressed concern, promotes understanding, and supports emotional adjustment during recovery.
Correct Answer Is:
d) "The removal of a single testicle will not prevent you from having an erection."
3.

A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps?

  • Record the client's vital signs.
  • Measure the client's abdominal girth.
  • Prime the client's catheter tubing with dialysate solution.
  • Infuse dialysate solution into the client's peritoneal cavity.
  • Open the client's drainage tubing after 10 min of dwell time.

Explanation

Explanation
a) Record the client's vital signs.
Baseline vital signs must be obtained before starting peritoneal dialysis because changes in blood pressure, heart rate, or respiratory status can indicate fluid shifts or complications. Establishing pre-procedure values allows the nurse to compare subsequent findings and quickly identify adverse reactions.

b) Measure the client's abdominal girth.
Measuring abdominal girth before the procedure helps assess fluid retention, abdominal distention, and provides a baseline to determine how the client tolerates the dialysate instillation. It is essential for identifying complications such as excessive fluid retention or discomfort.

c) Prime the client's catheter tubing with dialysate solution.
Priming removes air from the tubing and ensures that the dialysate flows smoothly into the peritoneal cavity. This prevents air infusion, which can cause abdominal discomfort and hinder proper fluid exchange.

d) Infuse dialysate solution into the client's peritoneal cavity.
Once the tubing is primed, the dialysate is infused into the cavity. This is the fill phase of peritoneal dialysis, allowing fluid and solutes to move across the peritoneal membrane during the dwell time.

e) Open the client's drainage tubing after 10 min of dwell time.
After the prescribed dwell period, the drainage tubing is opened to allow the dialysate to exit the peritoneal cavity. This completes the exchange cycle and allows evaluation of the drained fluid for clarity, volume, and potential complications.
Correct Answer Is:
a) Record the client's vital signs; b) Measure the client's abdominal girth; c) Prime the client's catheter tubing with dialysate solution; d) Infuse dialysate solution into the client's peritoneal cavity; e) Open the client's drainage tubing after 10 min of dwell time.
4.

A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD?

  • Ensure two fingers fit between the leg and the sleeve.
  • Wrap excess tubing to the side of each leg.
  • Ensure pressure of the device is at 25 mmHg.
  • Place each sleeve under each leg with the opening at the calf.

Explanation

Explanation
When applying an SCD, the sleeve must be snug enough to provide effective compression but not tight enough to impair circulation. Ensuring that two fingers fit between the client’s leg and the sleeve confirms proper fit and prevents skin breakdown or circulatory compromise. Tubing should not be wrapped tightly, pressure settings are regulated by the machine (not preset at 25 mmHg), and the sleeve should wrap evenly around the leg—not with the opening at the calf.
Correct Answer Is:
a) Ensure two fingers fit between the leg and the sleeve.
5.

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

  • Incision healing well
  • Client status unchanged throughout shift
  • Abdominal wound dry, without redness
  • Client received an adequate amount of fluid

Explanation

Explanation
c) Abdominal wound dry, without redness
Documentation must be objective, specific, and measurable. The statement “abdominal wound dry, without redness” provides clear, descriptive findings that accurately reflect the client’s condition and can be compared with future assessments. This type of documentation supports continuity of care and allows the provider to evaluate healing progress. Subjective or vague statements such as “healing well,” “unchanged,” or “adequate” lack detail, are open to interpretation, and do not meet professional documentation standards.
Correct Answer Is:
c) Abdominal wound dry, without redness
6.

A nurse is monitoring a client who has a nasogastric (NG) tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report?

  • Potassium 4.2 mEq/L
  • BUN 16 mg/dL
  • Abdominal distention
  • Bile-colored drainage from the NG tube

Explanation

Explanation
Abdominal distention indicates that the obstruction may be worsening or that the NG tube is not effectively decompressing the stomach and intestines. This can signal impaired bowel function, increasing pressure, or risk for perforation. Because distention suggests a failure of current therapy and potential deterioration, it requires immediate provider notification. Potassium and BUN values are within normal limits, and bile-colored drainage is expected with NG suction in an obstruction.
Correct Answer Is:
c) Abdominal distention
7.

A nurse is reinforcing teaching with a client who wants to lose 0.9 kg (2 lb) of body fat per week. The nurse knows that 0.45 kg (1 lb) of body fat equals 3,500 calories. The nurse should instruct the client to reduce his daily caloric intake by how many calories?

  • 500 calories
  • 750 calories
  • 1,000 calories
  • 1,500 calories

Explanation

Explanation
Losing 2 lb per week requires creating a weekly deficit of 7,000 calories (because 1 lb = 3,500 calories, so 2 lb = 7,000 calories). To determine how many calories must be reduced per day, divide 7,000 by 7 days. This equals 1,000 calories per day, which is the daily caloric reduction needed for the client to safely lose 2 lb per week.
Correct Answer Is:
C. 1,000 calories
8.

A nurse is caring for a client who has a new prescription for nitroglycerin. The nurse should monitor for which of the following adverse effects of the medication?

  • Nocturia
  • Increased saliva production
  • Flushing
  • Fever

Explanation

Explanation
Nitroglycerin is a vasodilator that relaxes blood vessels to improve blood flow. This widening of blood vessels can cause increased blood flow to the skin, resulting in facial flushing or warmth. This is a common and expected adverse effect due to peripheral vasodilation. The nurse should reassure the client that flushing may occur and monitor for additional vasodilatory effects such as headache or hypotension.
Correct Answer Is:
C. Flushing
9.

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

  • Activate the fire alarm system.
  • Use a fire extinguisher at the source of the smoke.
  • Assist the client to a nearby common area.
  • Close the doors to the room and to the bathroom.

Explanation

Explanation
According to the RACE fire safety protocol (Rescue, Alarm, Contain, Extinguish), the first priority is to rescue the client from immediate danger. Smoke in the bathroom indicates a potential fire hazard, and removing the client from the room ensures their safety before any other steps are taken. Once the client is safe, the nurse would then activate the alarm, close doors to contain the fire, and attempt to extinguish it if safe to do so.
Correct Answer Is:
C. Assist the client to a nearby common area.
10.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

  • Empty urine from the drainage bag every 12 hrs.
  • Secure the catheter tubing to the client's thigh.
  • Apply topical antimicrobial ointment to the client's urinary meatus following catheter care.
  • Use clean technique to collect urine specimens from the drainage system.

Explanation

Explanation
b) Secure the catheter tubing to the client's thigh.
Securing the catheter tubing to the client’s thigh prevents unnecessary traction on the catheter, reduces urethral trauma, and significantly lowers the risk of catheter-associated urinary tract infections. Stabilization helps keep the catheter in proper position and minimizes discomfort. The drainage bag should be emptied at least every 8 hours, antimicrobial ointments are not recommended because they can cause irritation, and collecting urine specimens requires sterile—not clean—technique.
Correct Answer Is:
b) Secure the catheter tubing to the client's thigh.

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