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ATI RN & PN Medical Surgical Nursing Exam Version 1–
Adult Health Disorders and Nursing Interventions
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is teaching a client with hypertension about the DASH diet. Which food choice by the client indicates an understanding of the teaching? A. Canned vegetable soup B. Processed deli meats C. Fresh fruits and vegetables D. Salted pretzels Ans: C Rationale: The DASH diet focuses on reducing sodium intake and increasing the consumption of nutrients that lower blood pressure. Fresh fruits and vegetables are naturally low in sodium and high in potassium and fiber. Canned soups and processed meats are typically very high in sodium and should be avoided. The client should aim for several servings of fruits and vegetables daily to manage hypertension effectively. High sodium intake leads to fluid retention and increased vascular resistance. Education on reading food labels for sodium content is a critical nursing intervention. This dietary approach helps in preventing long-term complications like stroke or heart disease. Success is measured by the client’s ability to choose whole foods over processed alternatives.
2. Which of the following is a classic symptom of left-sided heart failure? A. Jugular venous distention B. Dyspnea and crackles C. Peripheral edema D. Liver enlargement Ans: B Rationale: Left-sided heart failure primarily affects the pulmonary system because the left ventricle cannot pump blood efficiently to the body. This causes blood to back up into the lungs, leading to pulmonary congestion. Symptoms like dyspnea and crackles are direct results of fluid entering the alveolar spaces. Right-sided heart failure involves systemic congestion, such as peripheral edema and jugular venous distention. The nurse must prioritize respiratory assessments for patients with left-sided failure. Diuretics are often prescribed to reduce the fluid volume and ease the workload on the heart. Monitoring oxygen saturation levels is essential for these patients. Proper positioning, such as sitting upright, can also help improve breathing and comfort.
4. What is the priority nursing intervention for a client experiencing an acute asthma attack? A. Administering a short-acting beta-2 agonist inhaler B. Providing a high-protein snack C. Administering a dose of oral corticosteroids D. Encouraging the client to lie flat Ans: A Rationale: During an acute asthma attack, the primary goal is to relieve airway constriction quickly. Short-acting beta-2 agonists like albuterol work rapidly to bronchodilate the airways. Oral corticosteroids are important for reducing inflammation but do not provide immediate relief. The nurse should place the client in a high-Fowler’s position to maximize lung expansion. Assessing lung sounds and oxygen saturation is vital throughout the intervention. Providing a calm environment helps reduce the patient’s anxiety and work of breathing. The nurse must stay with the client until the respiratory distress resolves. Teaching about the use of rescue versus maintenance inhalers is a long-term goal.
5. A client with COPD is being discharged. Which breathing technique should the nurse teach to help the client manage dyspnea? A. Rapid, shallow breathing B. Holding the breath for 10 seconds C. Pursed-lip breathing D. Coughing every 5 minutes Ans: C Rationale: Pursed-lip breathing is a technique used to slow down the breathing rate and keep airways open longer. This technique helps clients with COPD release trapped air from the lungs more effectively. It involves inhaling through the nose and exhaling slowly through puckered lips. This process reduces the work of breathing and improves gas exchange in the alveoli. The nurse should demonstrate the technique and have the client practice it during the assessment. It is particularly useful during physical activity or when the client feels short of breath. Regular use of this technique can improve the client’s overall exercise tolerance. This simple intervention empowers the client to manage their symptoms at home.
7. A nurse is caring for a client with a new diagnosis of Gastroesophageal Reflux Disease (GERD). Which instruction should the nurse include in the teaching? A. Avoid caffeine and chocolate B. Eat a large meal right before bedtime C. Lie down immediately after eating D. Wear tight-fitting clothing around the waist Ans: A Rationale: GERD management involves lifestyle and dietary modifications to prevent acid reflux. Certain foods like caffeine, chocolate, and fatty foods relax the lower esophageal sphincter. This relaxation allows stomach acid to flow back into the esophagus, causing irritation. Clients should be advised to eat small, frequent meals instead of large ones. It is important to remain upright for at least two to three hours after eating. Tight-fitting clothing can increase intra-abdominal pressure and worsen symptoms. Elevating the head of the bed during sleep can also provide significant relief. These interventions aim to reduce the frequency of heartburn and prevent esophageal damage.
8. A nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most consistent with this condition? A. Pale, cool skin on the affected leg B. Unilateral swelling and warmth of the calf C. Absence of a pedal pulse D. Bilateral pitting edema Ans: B Rationale: DVT typically presents as unilateral swelling, redness, and warmth in the affected extremity. The calf may feel tender to the touch, and the patient may report pain. It is a serious condition that requires immediate medical attention to prevent a pulmonary embolism. Nurses should avoid massaging the area to prevent dislodging the clot. Elevating the affected limb and maintaining bed rest are common initial interventions. Anticoagulant therapy is usually started to prevent the clot from growing. Diagnostic tests like a venous duplex ultrasound are used to confirm the diagnosis. Patient education on avoiding prolonged immobility is crucial for preventing recurrence.
10. A nurse is caring for a client who underwent a total hip arthroplasty. Which action is necessary to prevent dislocation? A. Encourage the client to cross their legs B. Use an abduction pillow between the legs C. Keep the hip flexed at more than 90 degrees D. Turn the client onto the operative side immediately Ans: B Rationale: Post-operative care for a total hip arthroplasty involves strict positioning to prevent the new joint from dislocating. An abduction pillow helps keep the legs apart and prevents adduction. Crossing the legs or flexing the hip beyond 90 degrees increases the risk of the prosthesis popping out. The nurse should also instruct the client to use a raised toilet seat at home. Early ambulation with the assistance of physical therapy is encouraged for recovery. Monitoring for signs of infection and excessive drainage at the surgical site is important. Pain management is a priority to allow the patient to participate in rehabilitation. The nurse must ensure the patient understands these movements restrictions before discharge.
11. Which of the following is a primary sign of increased intracranial pressure (ICP) in a client with a head injury? A. Decreased level of consciousness B. Increased heart rate C. Increased urine output D. Lowered blood pressure Ans: A Rationale: A decrease in the level of consciousness (LOC) is often the earliest and most sensitive indicator of increasing ICP. As pressure within the skull rises, brain tissue is compressed, leading to cognitive and physical changes. The nurse should use the Glasgow Coma Scale (GCS) to objectively assess LOC. Other signs include severe headache, projectile vomiting, and changes in pupil reactivity. Cushing’s triad, which includes bradycardia and hypertension, is a late sign of severe ICP. Nursing interventions include elevating the head of the bed to 30 degrees to promote venous drainage. Avoiding activities that increase intra-abdominal pressure, like coughing, is also necessary. Prompt recognition and intervention are vital to prevent permanent brain damage.
13. A nurse is caring for a client with a new colostomy. Which finding should the nurse report to the provider immediately? A. The stoma is moist and pink B. Skin irritation around the stoma C. Small amounts of mucus in the bag D. The stoma is dark purple or black Ans: D Rationale: A healthy stoma should appear moist, red, or pink, similar to the inside of the mouth. A stoma that is dark purple, black, or very pale indicates a lack of blood flow and ischemia. This is a medical emergency and must be reported to the surgeon immediately to prevent tissue death. The nurse should assess the stoma’s appearance frequently in the immediate post-operative period. Mild skin irritation is common and can be managed with proper pouching techniques. Mucus production is a normal function of the intestinal lining. Education on stoma care and lifestyle adjustment is a major part of nursing care. Emotional support is also vital as the client adapts to their new body image.
14. A nurse is educating a client with osteoporosis. Which of the following is the most appropriate recommendation? A. Increase intake of sodium and caffeine B. Perform weight-bearing exercises regularly C. Avoid all physical activity to prevent fractures D. Limit Vitamin D intake to once a month Ans: B Rationale: Osteoporosis is a condition where bones become brittle and fragile due to loss of tissue. Weight-bearing exercises, such as walking or light jogging, help stimulate bone formation and increase density. In contrast, a sedentary lifestyle can lead to further bone loss and muscle weakness. Clients should also be encouraged to increase their intake of calcium and Vitamin D through diet or supplements. Avoiding tobacco and excessive alcohol is also important for maintaining bone health. The nurse should assess the home environment for fall hazards, like loose rugs or poor lighting. Medications like bisphosphonates may be prescribed to help strengthen the bones. Promoting safety is the primary goal of nursing care for these patients.
16. A client with cirrhosis has developed hepatic encephalopathy. Which medication does the nurse expect to administer to lower the ammonia level? A. Lactulose B. Furosemide C. Spironolactone D. Metoprolol Ans: A Rationale: Hepatic encephalopathy is caused by the liver’s inability to filter toxins, specifically ammonia, from the blood. Lactulose is an osmotic laxative that traps ammonia in the gut and promotes its excretion through stools. The goal of therapy is to achieve two to three soft bowel movements per day. Nurses should monitor the client’s mental status and neurological signs for improvement. High ammonia levels lead to symptoms like confusion, tremors (asterixis), and eventually coma. Diuretics like furosemide are used for ascites but do not lower ammonia levels directly. Proper nutrition, usually a moderate protein diet, is also important for managing cirrhosis. The nurse must balance the laxative effect of lactulose with the risk of dehydration.
17. A nurse is caring for a client with a chest tube. Which finding requires immediate intervention? A. Intermittent bubbling in the water seal chamber B. Tidaling in the water seal chamber with respirations C. Drainage of 50 mL in the first hour post-insertion D. Continuous bubbling in the water seal chamber Ans: D Rationale: Chest tubes are used to remove air or fluid from the pleural space to re-expand the lung. In the water seal chamber, tidaling (fluctuation with breathing) is a normal and expected finding. Intermittent bubbling is normal if the tube was placed to treat a pneumothorax as air escapes. However, continuous bubbling indicates an air leak in the system that must be located and fixed. The nurse should check all connections and the insertion site if a leak is suspected. Drainage amounts should be monitored and recorded regularly for changes. Sudden increases in bright red blood or excessive drainage (over 100 mL/hr) are also concerning. Keeping the drainage system below the level of the chest is essential for proper function.
19. A nurse is teaching a client about a colonoscopy procedure. Which statement should be included? A. You can eat a regular breakfast the morning of the procedure B. The procedure will be done under general anesthesia C. You will need to drink a bowel preparation solution the day before D. You should not drive home for at least 4 hours after the procedure Ans: C Rationale: A colonoscopy is a diagnostic procedure used to visualize the large intestine for abnormalities. Effective visualization requires a completely clean bowel, which is achieved through a clear liquid diet and a bowel prep solution. The client should be NPO for several hours before the procedure to ensure safety during sedation. Conscious sedation is typically used, meaning the patient is relaxed but not fully unconscious. After the procedure, it is normal to experience some cramping or gas. A responsible adult must drive the client home because of the effects of the sedative. The nurse should monitor for signs of bowel perforation, such as severe pain or fever, following the exam. This screening tool is vital for the early detection of colorectal cancer. 20. Which electrolyte imbalance is a client with excessive vomiting most at risk for developing? A. Hypokalemia B. Hyperkalemia C. Hypernatremia D. Hypermagnesemia Ans: A
Rationale: Excessive vomiting leads to the loss of gastric acid and potassium, which can cause hypokalemia and metabolic alkalosis. Potassium is a vital electrolyte for muscle function and heart rhythm. The nurse should monitor the client for signs of weakness, leg cramps, or irregular heartbeats. Lab values should be checked frequently to guide replacement therapy. Intravenous potassium may be necessary if the deficiency is severe, but it must never be given via IV push. Encouraging the intake of potassium-rich fluids like broth is helpful if the client can tolerate oral intake. Rehydration with isotonic fluids is also a priority to treat volume depletion. Constant monitoring of vital signs helps detect early signs of dehydration or cardiac issues.
21. What is the primary purpose of a ‘pursed-lip’ breathing technique for a patient with emphysema? A. To increase the respiratory rate B. To promote carbon dioxide elimination C. To strengthen the diaphragm D. To reduce the amount of oxygen needed Ans: B Rationale: Emphysema involves the destruction of alveoli, leading to air trapping and inefficient gas exchange. Pursed-lip breathing creates back-pressure in the airways, which helps keep them open during exhalation. This allows the patient to exhale more completely and get rid of excess carbon dioxide. It also helps to prevent the collapse of small airways, which is common in obstructive lung diseases. The nurse should instruct the patient to inhale through the nose for two seconds and exhale through pursed lips for four. This controlled breathing pattern helps reduce the feeling of breathlessness and anxiety. It is a cost- effective and non-invasive way for patients to manage their symptoms. Consistent practice improves the patient’s functional capacity during daily activities.
