ATI PN Medical Surgical
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Free ATI PN Medical Surgical Questions
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
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Measure the client's intake and output every 8 hr.
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Dim the lighting in the client's room.
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Monitor the client's temperature every 6 hr.
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Initiate contact precautions for the client.
Explanation
Explanation
Clients with viral meningitis commonly experience photophobia, severe headache, and hypersensitivity to environmental stimuli because inflammation of the meninges increases intracranial irritation. Dimming the lights directly reduces sensory stimulation and helps decrease headache intensity and discomfort. This intervention supports neurologic rest and decreases agitation. Unlike bacterial meningitis, viral meningitis does not require special isolation beyond standard precautions. Frequent neurologic and temperature monitoring is important but must occur more often than every 6 hours. Intake and output monitoring is not priority unless complications arise. Dimming the lighting is the most immediate and appropriate intervention to promote comfort and reduce neurologic stress.Correct Answer Is:
B. Dim the lighting in the client's room.A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
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Instruct the client to tilt their head back to facilitate swallowing.
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Schedule physical therapy directly before meals.
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Provide oral care before meals.
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Encourage the client to use a straw.
Explanation
Explanation
Providing oral care before meals helps reduce the risk of aspiration in clients with dysphagia. Clearing the mouth of secretions, debris, or bacteria improves the client’s ability to control food and swallow safely. Oral hygiene also enhances taste sensation, stimulates saliva production, and promotes a more effective swallowing response, all of which support safer eating for clients recovering from a stroke.Correct Answer Is:
C. Provide oral care before meals.The nurse is reinforcing teaching about foot care to the diabetic client. Which of the following statements should the nurse make?
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"Remove any calluses or corns when they develop."
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"Do not use any foot powder as a remedy for sweating feet."
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"Apply lotion to feet and in between toes to keep skin soft."
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"The best time to perform nail care is after a bath or shower."
Explanation
Explanation
Warm water softens toenails, making them easier and safer to trim. This is especially important for diabetic clients, who are at increased risk for skin injury, infection, and poor wound healing. Cutting nails when they are softened reduces the chance of causing small cuts, jagged edges, or ingrown nails. Proper nail care after bathing supports safe foot hygiene and helps prevent complications that can progress quickly in clients with diabetes.Correct Answer Is:
D. "The best time to perform nail care is after a bath or shower."A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?
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"I will take four nitroglycerin sublingual tablets if I have chest pain."
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"I will have hot, dry, and flushed skin if I am having a heart attack."
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"I will wait 30 minutes before taking action if I have heartburn."
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"I will notify emergency response if I have sudden jaw pain."
Explanation
Explanation
Sudden jaw pain is a classic sign of myocardial ischemia, especially in clients with angina. Recognizing that pain radiating to the jaw, arm, back, or neck may indicate a heart attack—and requires immediate emergency response—shows correct understanding of angina education. Early recognition and rapid action are essential to prevent myocardial damage and improve outcomes.Correct Answer Is:
D. "I will notify emergency response if I have sudden jaw pain."A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take?
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Rinse the client's mouth twice daily with an alcohol-based mouthwash.
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Increase the client's fluid intake to 2,000 mL daily.
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Offer the client hot beverages to drink.
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Provide the client with a high-protein diet.
Explanation
Explanation
d) Provide the client with a high-protein diet.A high-protein diet supports tissue repair and healing, which is essential for clients with stomatitis. Protein promotes regeneration of damaged oral mucosa and strengthens immune function, helping reduce inflammation and discomfort. This intervention directly assists recovery of the irritated tissue caused by poorly fitting dentures. Alcohol-based mouthwash and hot beverages worsen irritation, while increased fluids alone do not directly promote mucosal healing.
Correct Answer Is:
d) Provide the client with a high-protein diet.A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
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Apply a motion sensor mat to the client's bed.
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Move the overbed table away from the bed.
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Raise all four side rails while the client is in bed.
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Leave the television on in the client's room.
Explanation
Explanation
Clients who have dementia often attempt to get out of bed without calling for assistance. A motion sensor mat alerts staff as soon as the client tries to stand or move, allowing rapid intervention to prevent a fall. This is a non-restrictive, safety-enhancing strategy appropriate for nighttime when supervision is reduced. Early detection of movement is essential to maintaining safety in clients with cognitive impairment.Correct Answer Is:
A. Apply a motion sensor mat to the client's bed.A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?
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Complete Semmes-Weinstein monofilament testing following treatment.
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Apply the heating pad as prescribed by the provider.
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Clarify the prescription with the provider.
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Observe the skin 10 min after the start of treatment.
Explanation
Explanation
Clients with diabetic neuropathy have decreased sensation and a significantly increased risk of burns when heat is applied to their feet. Heating pads are contraindicated because the client may not perceive excessive heat or pain, leading to severe injury. Before performing any harmful intervention, the nurse must clarify the order to ensure client safety. This action aligns with safe practice and protects the client from preventable complications.Correct Answer Is:
c) Clarify the prescription with the provider.A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
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Numbness of the affected extremity.
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Muscle spasms.
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Warmth of the affected extremity.
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Absent pedal pulse.
Explanation
Explanation
A deep-vein thrombosis typically presents with localized warmth, swelling, tenderness, and redness in the affected limb due to inflammation and impaired venous return. Warmth is a key early indicator because the clot triggers an inflammatory response in the surrounding tissues. Recognizing this sign promptly is crucial to prevent serious complications such as pulmonary embolism, which can occur if part of the clot dislodges and travels to the lungs.Correct Answer Is:
C. Warmth of the affected extremity.The nurse is reinforcing teaching about a Transcutaneous Electrical Nerve Stimulation (TENS). Which of the following statements by the nurse is accurate?
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"This form of pain management involves tiny needles inserted into the skin and subcutaneous tissues."
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"This form of pain management focuses on a pleasant thought to divert focus."
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"This form of pain management involves meditation, yoga, and progressive muscle relaxation."
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"This form of pain management involves mild electrical stimulus applied to the area of pain."
Explanation
Explanation
A TENS unit works by delivering a mild electrical current through electrodes placed on the skin near the painful area. This electrical stimulation helps block pain signals from reaching the brain and encourages the release of endorphins, the body's natural pain relievers. It is a noninvasive, drug-free method of pain control and is commonly used for musculoskeletal pain and neuropathic discomfort.Correct Answer Is:
d) "This form of pain management involves mild electrical stimulus applied to the area of pain."A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hrs of using nitroglycerin?
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Atorvastatin
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Metformin
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Sildenafil
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Omeprazole
Explanation
Explanation
Nitroglycerin causes vasodilation to relieve chest pain, and sildenafil is also a potent vasodilator used for erectile dysfunction. When taken together, these medications can produce a severe and potentially life-threatening drop in blood pressure. This profound hypotension can lead to dizziness, syncope, shock, or even cardiac arrest. Clients must avoid sildenafil and other phosphodiesterase type 5 inhibitors within 24 hours of nitroglycerin use to prevent dangerous cardiovascular collapse.Correct Answer Is:
c) SildenafilHow to Order
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