ATI-AMS ATI Adult medical surgical Exam - Set 5 - Part 3

Correct Answer: Hypovolemic shock from blood loss

Saturating a perineal pad within an hour signals excessive vaginal bleeding after hysterectomy, which raises concern for hypovolemic shock from blood loss. The nurse monitors for hypotension and tachycardia and notifies the provider. Option b is incorrect because paralytic ileus presents with absent bowel sounds and abdominal distention, not heavy vaginal bleeding. The saturated pads point to blood loss, so an ileus describes a different postoperative complication unrelated to this finding. Option c is incorrect because atelectasis involves diminished breath sounds and impaired lung expansion after surgery, which has nothing to do with vaginal bleeding. This respiratory complication does not explain the soaked pads the nurse is seeing. Option d is incorrect because a psychological reaction such as persistent sadness is an emotional complication addressed with counseling, not a cause of excessive bleeding. It does not account for the physical sign of pad saturation indicating hemorrhage

Correct Answer: Do not apply deodorant or powder

Deodorant, lotion, and powder in the breast or underarm area can appear as shadows on a mammogram, so the client is told to avoid them. This preparation keeps the images clear and accurate. Option a is incorrect because drinking water beforehand is unnecessary for a mammogram, which images breast tissue rather than relying on a full bladder. Loading up on fluids would not improve the test and is not part of the preparation. Option b is incorrect because aspirin does not affect the accuracy of a mammogram and is not required or restricted for this imaging. Recommending it adds an irrelevant step, since the real concern is avoiding products that create shadows. Option c is incorrect because fasting is not needed for a mammogram because it does not involve sedation or contrast that requires an empty stomach. Telling the client not to eat applies a preparation meant for other procedures.

Correct Answer: Keep your abdominal muscles relaxed

Kegel exercises strengthen the pelvic floor by contracting the circumvaginal and perirectal muscles while keeping the abdomen relaxed. The client holds each contraction briefly and repeats them many times daily in various positions. Option b is incorrect because tightening the abdominal muscles defeats the purpose, since the goal is to isolate and strengthen the pelvic floor. Engaging the abdomen shifts the effort away from the target muscles the exercise is meant to build. Option c is incorrect because each contraction is held briefly rather than for a full minute, followed by a short relaxation. Holding for a minute is excessive and does not match the recommended technique for these pelvic floor exercises. Option d is incorrect because these exercises can be done lying, sitting, or standing, so limiting them to a lying position is unnecessarily restrictive. The flexibility to perform them in any position helps the client practice them many times each day.

Correct Answer: Draw the PSA before the rectal exam

The PSA blood sample is obtained before the digital rectal exam because palpating the prostate irritates the gland and can falsely raise the PSA level. Drawing it first preserves the accuracy of the result. Option a is incorrect because performing the rectal exam first stimulates the prostate and elevates the PSA, distorting the blood result. Reversing the order would produce a misleadingly high value and defeat the purpose of timing the draw correctly. Option b is incorrect because drawing the sample during the rectal exam captures the PSA when palpation has already raised it. Collecting blood at that moment yields an inaccurate level, so the draw must precede the examination entirely. Option d is incorrect because a recent urinary infection can elevate the PSA for weeks, so testing soon after one gives an unreliable result. Scheduling both tests right after an infection introduces a false elevation rather than ensuring accuracy.

Correct Answer: A continuous urge to void

The large catheter balloon is taped to the leg with traction to compress the prostatic fossa, producing a continuous urge to void. The nurse explains this is expected and instructs the client not to void around the catheter. Option a is incorrect because the expected sensation is a constant urge from balloon pressure, not sharp pain limited to urinating. Describing pain only with urination misrepresents the postoperative experience and could alarm the client about a normal feeling. Option b is incorrect because a complete absence of pressure does not occur because the inflated balloon and traction deliberately create a sensation of fullness. Telling the client to expect no pressure contradicts the continuous urge that the catheter produces. Option c is incorrect because the urge persists as long as the catheter balloon remains in place, rather than fading after an hour. Suggesting it will disappear quickly gives the client an inaccurate expectation of this ongoing postoperative sensati

Correct Answer: Collect it before starting antimicrobials

A culture should be collected from the purulent drainage before antimicrobial therapy begins so the causative organism can be identified accurately. Starting antibiotics first would alter the results and obscure the true pathogen. Option a is incorrect because starting antibiotics before collecting the specimen suppresses the organism and can produce a falsely negative or misleading culture. The sample must be obtained first so the laboratory can isolate the actual pathogen causing the infection. Option b is incorrect because povidone-iodine could kill organisms at the site and interfere with the culture, so soap and water is used for skin preparation instead. Cleansing with the antiseptic first would compromise the accuracy of the specimen. Option d is incorrect because a viral specimen is placed immediately on ice and sent without delay rather than refrigerated for hours. Holding it for an extended time would degrade the sample, so this handling does not preserve the specimen properl

Correct Answer: I will leave the scales in place

Removing psoriasis scales can cause bleeding, so the client is taught to leave them in place. Recognizing that scales should not be picked or scrubbed off shows correct understanding of safe skin care. Option a is incorrect because scrubbing the scales off injures the skin beneath and triggers bleeding, which the teaching specifically warns against. Choosing to remove them shows the client has not grasped why the scales are left undisturbed. Option c is incorrect because topical corticosteroids are avoided on the face and skin folds because the thin skin there is prone to thinning and yeast overgrowth. Applying the cream to the face disregards this precaution and could damage delicate tissue. Option d is incorrect because steroid creams require periodic medication vacations to prevent skin thinning and striae, rather than continuous use. Keeping the cream on the same area without breaks reflects a misunderstanding of safe application of the medication.

Correct Answer: Superficial-thickness burn

A severe sunburn that is pink to red, painful, and without blisters damages only the epidermis, which defines a superficial-thickness burn. These burns heal within several days without scarring. Option a is incorrect because a deep partial-thickness burn extends into the deeper dermis with a red-white appearance and soft eschar, far more involved than a simple sunburn. The painful, blister-free reddened skin described does not reach this depth. Option b is incorrect because a full-thickness burn destroys the entire epidermis and dermis with hard, inelastic eschar and little or no sensation. The client's painful, intact red skin is the opposite of the numb, leathery tissue seen in such burns. Option c is incorrect because a deep full-thickness burn reaches muscle, tendon, or bone and is painless because nerves are destroyed. The painful, superficial redness of a sunburn is nowhere near this severity, making this classification far too deep.

Correct Answer: Report these findings immediately

Hoarseness, a brassy cough, and drooling indicate inhalation injury with impending airway obstruction, so the nurse reports these findings immediately. Prompt intervention is needed before swelling closes off the airway. Option a is incorrect because these are warning signs of an airway emergency, not an expected response to a burn. Recording them as normal would delay the urgent action required and risk losing the airway as edema progresses. Option b is incorrect because applying ice to the neck does not relieve airway swelling and wastes critical time while the obstruction develops. The client needs immediate reporting and airway support, not a local measure that fails to address the danger. Option d is incorrect because offering fluids to a client with drooling and impending airway compromise risks aspiration and does nothing to relieve the swelling. Oral intake is unsafe here, so encouraging drinking ignores the airway threat entirely.

Correct Answer: Increasing the rate of IV fluids

During burn resuscitation, a falling urine output reflects inadequate fluid volume from capillary leak, so the nurse anticipates increasing the IV fluid rate. Restoring volume improves perfusion and brings urine output back toward the target. Option a is incorrect because a diuretic is not given for low urine output during burn resuscitation because the problem is volume depletion, not fluid overload. Forcing diuresis would worsen the deficit, so increasing fluids, not removing them, is correct. Option b is incorrect because restricting intake during the emergent phase would deepen the hypovolemia caused by massive fluid shifts into the tissues. The client needs more volume to maintain perfusion, making fluid restriction the opposite of the right response. Option c is incorrect because withholding intravenous fluids removes the very treatment that corrects the low output and supports circulation in a major burn. Stopping fluids would accelerate shock rather than restore the urine outpu