ATI RN ADULT MEDICAL–SURGICAL NURSING II (RN)
COMPREHENSIVE EXAM ACTUAL QUESTIONS AND
ANSWERS - LATEST AND COMPLETE UPDATE WITH
VERIFIED SOLUTIONS – ASSURED PASS WITH INSTANT
DOWNLOAD PDF.
1. A nurse is caring for a client with acute decompensated heart failure who is
receiving IV furosemide. Which assessment finding requires the most
immediate intervention?
A. Potassium level of 3.2 mEq/L
B. Crackles that have progressed from the bases to the mid-lung fields
C. Urine output of 45 mL/hr
D. Blood pressure of 148/86 mm Hg
Rationale: Progressive crackles indicate worsening pulmonary edema and
impaired gas exchange, which is immediately life-threatening. Hypokalemia
is significant but not as immediately life-threatening as respiratory
compromise.
2. A client with atrial fibrillation is prescribed warfarin. Which statement by
the client indicates correct understanding of teaching?
A. “I will increase my intake of green leafy vegetables.”
B. “I should stop the medication if I have bruising.”
C. “I need to have my INR checked regularly.”
D. “This medication works immediately to prevent clots.”
Rationale: Warfarin requires routine INR monitoring to ensure therapeutic
anticoagulation. Vitamin K intake should be consistent, bruising should be
reported, and onset is delayed.
3. A nurse is evaluating ECG findings in a client with chest pain. Which
rhythm is most associated with acute myocardial ischemia?
, A. Sinus bradycardia
B. ST-segment elevation
C. Prolonged PR interval
D. Peaked T waves
Rationale: ST-segment elevation is characteristic of acute myocardial injury
and ischemia requiring rapid intervention.
4. A client with COPD is receiving oxygen via nasal cannula at 2 L/min.
Which finding indicates the therapy is effective?
A. PaCO₂ of 52 mm Hg
B. Respiratory rate of 28/min
C. Oxygen saturation of 90%
D. Use of accessory muscles
Rationale: Target oxygen saturation for COPD clients is typically 88–92%.
Higher levels risk suppressing respiratory drive.
5. A nurse is suctioning a client with an endotracheal tube. Which action is
appropriate?
A. Apply continuous suction for 30 seconds
B. Preoxygenate the client before suctioning
C. Instill normal saline routinely
D. Hyperextend the neck during suctioning
Rationale: Preoxygenation reduces hypoxia. Suctioning should be
intermittent and brief; saline is not routinely recommended.
6. A client with pneumonia is prescribed incentive spirometry. Which
instruction should the nurse provide?
A. Use the device once per shift
B. Inhale slowly and deeply through the mouthpiece
C. Exhale forcefully into the device
, D. Perform while lying flat
Rationale: Incentive spirometry promotes lung expansion through slow,
deep inhalation.
7. A nurse is caring for a client with acute kidney injury (AKI). Which
laboratory value is most concerning?
A. Sodium 138 mEq/L
B. Potassium 6.1 mEq/L
C. Calcium 8.6 mg/dL
D. Hemoglobin 11.5 g/dL
Rationale: Hyperkalemia can cause fatal dysrhythmias and requires
immediate intervention.
8. A client receiving hemodialysis reports muscle cramps during treatment.
What is the priority nursing action?
A. Administer prescribed opioid analgesic
B. Slow the rate of dialysis
C. Assess blood pressure
D. Apply warm compresses
Rationale: Muscle cramps often result from hypotension during dialysis;
blood pressure assessment guides intervention.
9. A nurse is teaching a client with type 1 diabetes about insulin administration.
Which statement indicates correct understanding?
A. “I will mix glargine with regular insulin.”
B. “I should massage the site after injection.”
C. “I will rotate injection sites within the same anatomic area.”
D. “I can inject insulin into areas with lipohypertrophy.”
Rationale: Rotating within one anatomic area promotes consistent
absorption; glargine should not be mixed.
, 10.A client with diabetic ketoacidosis (DKA) is receiving IV insulin. Which
finding indicates improvement?
A. Blood glucose of 250 mg/dL
B. Decreased serum ketones
C. Serum potassium of 3.4 mEq/L
D. pH of 7.30
Rationale: Resolution of ketosis is the primary indicator of DKA
improvement.
11.A nurse is assessing a client with hyperthyroidism. Which finding is
expected?
A. Weight gain
B. Cold intolerance
C. Heat intolerance
D. Bradycardia
Rationale: Hyperthyroidism increases metabolic rate, causing heat
intolerance and tachycardia.
12.A client is receiving total parenteral nutrition (TPN). Which complication is
the nurse most vigilant to detect initially?
A. Fluid volume deficit
B. Infection
C. Hypoglycemia
D. Electrolyte dilution
Rationale: Central line–associated bloodstream infection is a major risk
with TPN.
13.A client with cirrhosis has ascites. Which assessment finding indicates
worsening portal hypertension?
A. Decreased abdominal girth
COMPREHENSIVE EXAM ACTUAL QUESTIONS AND
ANSWERS - LATEST AND COMPLETE UPDATE WITH
VERIFIED SOLUTIONS – ASSURED PASS WITH INSTANT
DOWNLOAD PDF.
1. A nurse is caring for a client with acute decompensated heart failure who is
receiving IV furosemide. Which assessment finding requires the most
immediate intervention?
A. Potassium level of 3.2 mEq/L
B. Crackles that have progressed from the bases to the mid-lung fields
C. Urine output of 45 mL/hr
D. Blood pressure of 148/86 mm Hg
Rationale: Progressive crackles indicate worsening pulmonary edema and
impaired gas exchange, which is immediately life-threatening. Hypokalemia
is significant but not as immediately life-threatening as respiratory
compromise.
2. A client with atrial fibrillation is prescribed warfarin. Which statement by
the client indicates correct understanding of teaching?
A. “I will increase my intake of green leafy vegetables.”
B. “I should stop the medication if I have bruising.”
C. “I need to have my INR checked regularly.”
D. “This medication works immediately to prevent clots.”
Rationale: Warfarin requires routine INR monitoring to ensure therapeutic
anticoagulation. Vitamin K intake should be consistent, bruising should be
reported, and onset is delayed.
3. A nurse is evaluating ECG findings in a client with chest pain. Which
rhythm is most associated with acute myocardial ischemia?
, A. Sinus bradycardia
B. ST-segment elevation
C. Prolonged PR interval
D. Peaked T waves
Rationale: ST-segment elevation is characteristic of acute myocardial injury
and ischemia requiring rapid intervention.
4. A client with COPD is receiving oxygen via nasal cannula at 2 L/min.
Which finding indicates the therapy is effective?
A. PaCO₂ of 52 mm Hg
B. Respiratory rate of 28/min
C. Oxygen saturation of 90%
D. Use of accessory muscles
Rationale: Target oxygen saturation for COPD clients is typically 88–92%.
Higher levels risk suppressing respiratory drive.
5. A nurse is suctioning a client with an endotracheal tube. Which action is
appropriate?
A. Apply continuous suction for 30 seconds
B. Preoxygenate the client before suctioning
C. Instill normal saline routinely
D. Hyperextend the neck during suctioning
Rationale: Preoxygenation reduces hypoxia. Suctioning should be
intermittent and brief; saline is not routinely recommended.
6. A client with pneumonia is prescribed incentive spirometry. Which
instruction should the nurse provide?
A. Use the device once per shift
B. Inhale slowly and deeply through the mouthpiece
C. Exhale forcefully into the device
, D. Perform while lying flat
Rationale: Incentive spirometry promotes lung expansion through slow,
deep inhalation.
7. A nurse is caring for a client with acute kidney injury (AKI). Which
laboratory value is most concerning?
A. Sodium 138 mEq/L
B. Potassium 6.1 mEq/L
C. Calcium 8.6 mg/dL
D. Hemoglobin 11.5 g/dL
Rationale: Hyperkalemia can cause fatal dysrhythmias and requires
immediate intervention.
8. A client receiving hemodialysis reports muscle cramps during treatment.
What is the priority nursing action?
A. Administer prescribed opioid analgesic
B. Slow the rate of dialysis
C. Assess blood pressure
D. Apply warm compresses
Rationale: Muscle cramps often result from hypotension during dialysis;
blood pressure assessment guides intervention.
9. A nurse is teaching a client with type 1 diabetes about insulin administration.
Which statement indicates correct understanding?
A. “I will mix glargine with regular insulin.”
B. “I should massage the site after injection.”
C. “I will rotate injection sites within the same anatomic area.”
D. “I can inject insulin into areas with lipohypertrophy.”
Rationale: Rotating within one anatomic area promotes consistent
absorption; glargine should not be mixed.
, 10.A client with diabetic ketoacidosis (DKA) is receiving IV insulin. Which
finding indicates improvement?
A. Blood glucose of 250 mg/dL
B. Decreased serum ketones
C. Serum potassium of 3.4 mEq/L
D. pH of 7.30
Rationale: Resolution of ketosis is the primary indicator of DKA
improvement.
11.A nurse is assessing a client with hyperthyroidism. Which finding is
expected?
A. Weight gain
B. Cold intolerance
C. Heat intolerance
D. Bradycardia
Rationale: Hyperthyroidism increases metabolic rate, causing heat
intolerance and tachycardia.
12.A client is receiving total parenteral nutrition (TPN). Which complication is
the nurse most vigilant to detect initially?
A. Fluid volume deficit
B. Infection
C. Hypoglycemia
D. Electrolyte dilution
Rationale: Central line–associated bloodstream infection is a major risk
with TPN.
13.A client with cirrhosis has ascites. Which assessment finding indicates
worsening portal hypertension?
A. Decreased abdominal girth
