Question

A nurse is caring for a client who is 1 day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Assess pedal pulse on left leg.

Rationale :

🌟 Comparing pulses bilaterally identifies whether the diminished pulse is due to systemic changes or localized compromised perfusion.

🌟 A femoral-popliteal bypass graft is at high risk for occlusion, and comparison helps identify early graft failure.

🌟 A pulse difference between extremities helps determine whether the issue is vascular insufficiency or a temporary assessment error.

🌟 Immediate pulse comparison is essential to evaluate for critical limb ischemia.

🌟 This assessment guides whether urgent provider notification or interventions are required.

Assess surgical incision for infection

🌟 Infection does NOT cause acute pulse changes on postoperative day 1.

Assist to ambulate

🌟 Ambulation is unsafe until perfusion status is confirmed.

Elevate the right leg

🌟 Elevation reduces arterial flow, worsening ischemia.

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Answer 2

Correct Answers

Blank 1 Correct Option: Cirrhosis
Blank 2 Correct Option: Measure abdominal girth and Teach sodium restriction
Blank 3 Correct Option: Ammonia levels and Pulse oximetry

Rationale :

💠 Abdominal distention, hepatomegaly, venous dilation, and dyspnea strongly indicate ascites from cirrhosis.

💠 Measuring abdominal girth monitors ascites progression, a key complication of liver disease.

💠 Sodium restriction decreases fluid retention, helping control ascites.

💠 Ammonia levels must be monitored to detect hepatic encephalopathy, a life-threatening condition.

💠 Pulse oximetry is necessary because ascites limits diaphragm expansion and impairs ventilation.

💠 Pancreatitis — symptoms would include epigastric pain and elevated amylase/lipase.

💠 Celiac disease/Crohn’s — not associated with ascites or hepatomegaly.

💠 Gluten teaching or diet adherence — unrelated to liver pathology.

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Answer 3

Correct Answers

Blank 1 Correct Option: Systemic lupus erythematosus (SLE)
Blank 2 Correct Option: Identify symptom triggers and Use sun protection
Blank 3 Correct Option: Corticosteroid adherence and Depression screening

Rationale :

🔷 Positive ANA, butterfly rash, alopecia, joint pain, and plaques strongly indicate SLE.

🔷 Identifying triggers (sun exposure, stress, illness) reduces flare-ups.

🔷 Sun exposure worsens SLE symptoms; UV protection prevents skin exacerbations.

🔷 Corticosteroids are a cornerstone treatment; adherence prevents organ complications.

🔷 Depression monitoring is essential due to body image changes and chronic illness burden.

🔷 Multiple sclerosis / Type 1 diabetes — do not match rash or ANA positivity.

🔷 Gluten teaching / carbohydrate counting — unrelated to SLE physiology.

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Answer 4

Correct Answers:

Review the medical record for type and cross-match information.

Rationale :

🌼 Type-and-cross ensures compatibility, the #1 safety step before transfusion.

🌼 Prevents hemolytic reactions, the most severe transfusion complication.

🌼 Verification allows proper matching of ABO and Rh status.

🌼 Checking documentation ensures orders align with correct patient and blood product.

🌼 Transfusion cannot proceed legally or safely without this verification.

Obtain blood before inserting catheter

🌼 Blood should be collected only when ready to start transfusion, not before line placement.

Prime with lactated Ringer’s

🌼 Only normal saline can prime blood tubing—LR risks clotting.

Identify using name + room number

🌼 Must use two approved identifiers, never room number.

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Answer 5

Correct Answers:

Erythema surrounding the wound

Rationale :

🌟 Erythema is a hallmark sign of early wound infection, indicating inflammation from bacterial activity.

🌟 Infection typically presents with redness, warmth, swelling, or pain around the incision.

🌟 Surrounding redness suggests the infection is spreading beyond the incision line.

🌟 Identifying infection early prevents complications such as abscess formation or sepsis.

🌟 This finding requires timely reassessment and provider notification.

Pink tissue inside wound

🌟 Indicates healthy epithelialization, not infection.

Serosanguinous drainage

🌟 Expected normal postoperative drainage unless excessive.

Granulation tissue

🌟 Sign of healing, not infection.

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Answer 6

Correct Answers:

Monitor pin site each shift.

Rationale :

💠 Skeletal traction involves metal pins inserted into bone, putting clients at high risk for pin-site infection.

💠 Monitoring each shift ensures early identification of drainage, redness, or loosening.

💠 Early detection prevents progression to osteomyelitis, a severe complication.

💠 Pin-site care is essential to maintain sterility and traction stability.

💠 Frequent checks ensure traction remains aligned and effective.

Remove weights for ADLs

💠 Weights must remain continuous; removing them disrupts alignment.

Check neurovascular status twice daily

💠 Must be checked every 1–2 hours, not twice daily.

Place weights on floor

💠 Weights must hang freely; placing them on the floor eliminates traction.

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Answer 7

Correct Answers:

"Treatment of outbreaks can include oral and topical medications."

Rationale :

🔶 HSV-2 outbreaks are managed with oral antivirals such as acyclovir, valacyclovir, or famciclovir.

🔶 Topical antivirals or anesthetic creams may help reduce discomfort during outbreaks.

🔶 Treatment shortens the duration of symptoms and decreases viral shedding.

🔶 Recurrence is common; having effective management strategies improves quality of life.

🔶 Antivirals reduce severity but do not cure HSV-2.

Use oil-based lubricants

🔶 Oil-based products increase irritation and can break condoms.

Cryotherapy prevents cancer

🔶 HSV is NOT linked to cancer; cryotherapy is used for warts, not herpes.

Daily antivirals prevent transmission

🔶 They reduce risk but do NOT eliminate transmission.

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Answer 8

Correct Answers:

"You can wear a support bra to bed to help reduce pain."

Rationale :

🟣 Fibrocystic breast changes cause cyclic breast tenderness, often relieved by support garments.

🟣 Wearing a support bra reduces movement-related pain, especially at night.

🟣 This condition is benign and often worsens before menstruation due to hormonal changes.

🟣 Comfort measures such as supportive bras and warm compresses are first-line management.

🟣 Education focuses on symptom relief, not aggressive treatment.

Tamoxifen therapy

🟣 Reserved for severe cases and not standard long-term therapy until menopause.

More pain after menses

🟣 Pain is typically before menses, not after.

Annual 3D mammograms

🟣 Not routinely indicated unless patient is high-risk.

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Answer 9

Correct Answers:

Reduced cravings

Rationale :

🌼 Methadone is a long-acting opioid agonist that reduces withdrawal symptoms.

🌼 Its primary therapeutic effect is decreasing opioid cravings, stabilizing recovery.

🌼 It prevents highs/lows, supporting functional daily living without intoxication.

🌼 This helps reduce relapse and supports long-term maintenance therapy.

🌼 Methadone does NOT induce euphoria when used correctly.

Dilated pupils

🌼 Suggest withdrawal, not therapeutic response.

Somnolence

🌼 Indicates possible overmedication or sedation.

Euphoria

🌼 Suggests misuse; methadone should NOT create a high.

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Answer 10

Correct Answers

Encourage the client to cough. [ Contraindicated ]
Elevate the head of the bed. [ Anticipated ]
Decrease oxygen to 1.5 L/min via nasal cannula. [ Contraindicated ]
Keep the client's head in a midline position [ Anticipated ]
Assist the client to the bathroom [ Contraindicated ]
Initiate seizure precautions. [ Anticipated ]

Rationale :

Elevate the head of the bed

🔷 Elevating HOB to 30 degrees promotes venous drainage and reduces intracranial pressure (ICP).

🔷 It improves oxygenation by easing work of breathing, especially with declining O₂ saturations.

🔷 This position reduces risk of aspiration in a client who has vomited.

🔷 Increased ICP + hypertension + agitation make positioning a priority intervention.

🔷 Helps prevent further neurological deterioration by improving cerebral perfusion.

Keep the head in a midline position

🔷 Midline positioning prevents jugular vein compression, promoting adequate cerebral venous outflow.

🔷 Turning the head can increase intracranial pressure, worsening the neurological status.

🔷 This positioning supports optimal cerebral perfusion pressure.

🔷 It is a standard intervention for patients displaying signs of ICP elevation.

🔷 Protects the brain from further swelling by maintaining neutral alignment.

Initiate seizure precautions

🔷 A sudden drop in GCS to 9, restlessness, and vomiting increase seizure risk.

🔷 Severe hypertension (210/76) suggests possible hypertensive encephalopathy, a seizure trigger.

🔷 Seizures worsen ICP, making early precautions essential for neuroprotection.

🔷 Decreased responsiveness indicates impaired cortical function.

🔷 Precautions reduce injury risk during a potential seizure event.

Encourage the client to cough

🔷 Coughing spikes intrathoracic pressure, significantly increasing ICP.

🔷 This client already shows signs of deteriorating neurological status.

Decrease oxygen to 1.5 L/min

🔷 O₂ saturation dropped from 95% → 90%, indicating worsening oxygenation.

🔷 Lowering oxygen worsens hypoxia, which increases ICP.

Assist to bathroom

🔷 Client is agitated, vomiting, and has a GCS of 9—unsafe for ambulation.

🔷 Movement increases metabolic demand and can worsen intracranial pressure

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Potential Prescription	Anticipated	Nonessential	Contraindicated
Encourage the client to cough.
Elevate the head of the bed.
Decrease oxygen to 1.5 L/min via nasal cannula.
Keep the client's head in a midline position
Assist the client to the bathroom
Initiate seizure precautions.

ATI RN Adult Medical Surgical 2023

No.

1 :
A nurse is caring for a client who is 1 day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 :
A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 :
A nurse in a provider's office is caring for a client.

Correct Answers

4 :
A nurse is preparing to administer a unit of packed RBCs to a female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

6 :
A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

7 :
A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

8 :
A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

9 :
A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

10 :
A nurse is caring for a client.

Correct Answers

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ATI RN Adult Medical Surgical 2023

No.

1 : A nurse is caring for a client who is 1 day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 : A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 : A nurse in a provider's office is caring for a client.

Correct Answers

4 : A nurse is preparing to administer a unit of packed RBCs to a female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 : A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

6 : A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

7 : A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

8 : A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

9 : A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

10 : A nurse is caring for a client.

Correct Answers

1 :
A nurse is caring for a client who is 1 day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 :
A nurse in an emergency department (ED) is caring for a client.

3 :
A nurse in a provider's office is caring for a client.

4 :
A nurse is preparing to administer a unit of packed RBCs to a female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

6 :
A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

7 :
A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

8 :
A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

9 :
A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

10 :
A nurse is caring for a client.