ATI RN ADULT MEDICAL-SURGICAL NURSING III (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 respiratory distress syndrome
(ARDS) who is receiving mechanical ventilation. Which intervention is the
priority to improve oxygenation?
A. Suctioning the airway every 2 hours
B. Positioning the client in prone position as prescribed
C. Administering IV fluids aggressively
D. Reducing positive end-expiratory pressure (PEEP)
Rationale: Prone positioning improves ventilation–perfusion matching and
oxygenation in ARDS. Aggressive fluids can worsen pulmonary edema,
suctioning does not address oxygenation directly, and reducing PEEP
decreases alveolar recruitment.
2. A client with chronic kidney disease is prescribed epoetin alfa. Which
outcome indicates the medication is effective?
A. Decreased serum potassium
B. Reduced blood urea nitrogen
C. Increased hemoglobin level
D. Improved urine output
Rationale: Epoetin alfa stimulates erythropoiesis, leading to increased
hemoglobin. It does not directly affect potassium, BUN, or urine output.
3. A nurse is assessing a client with suspected increased intracranial pressure
(ICP). Which finding requires immediate intervention?
A. Headache rated 6/10
, B. Unequal pupil size
C. Restlessness
D. Nausea
Rationale: Unequal pupils indicate possible brain herniation and require
immediate action. Headache, restlessness, and nausea are common but less
acute findings.
4. A client with heart failure is receiving furosemide. Which laboratory value
should the nurse monitor most closely?
A. Sodium
B. Calcium
C. Potassium
D. Glucose
Rationale: Loop diuretics cause potassium loss, increasing the risk for
hypokalemia and dysrhythmias.
5. A nurse is teaching a client with chronic obstructive pulmonary disease
(COPD) about pursed-lip breathing. What is the primary purpose of this
technique?
A. Increase tidal volume
B. Prevent airway collapse during exhalation
C. Decrease oxygen consumption
D. Strengthen respiratory muscles
Rationale: Pursed-lip breathing maintains positive airway pressure,
preventing airway collapse and improving gas exchange.
6. A client is admitted with a diagnosis of septic shock. Which intervention
should the nurse anticipate first?
A. Administration of vasopressors
B. Corticosteroid therapy
, C. Rapid infusion of IV crystalloid fluids
D. Blood transfusion
Rationale: Initial management of septic shock prioritizes rapid fluid
resuscitation to restore perfusion before vasopressors.
7. A nurse is caring for a client with cirrhosis and ascites. Which assessment
finding indicates worsening hepatic encephalopathy?
A. Jaundice
B. Asterixis
C. Abdominal distention
D. Spider angiomas
Rationale: Asterixis (flapping tremor) reflects elevated ammonia levels and
worsening encephalopathy.
8. A client receiving heparin therapy develops a platelet count of 80,000/mm³.
What is the nurse’s priority action?
A. Reduce the heparin dose
B. Administer vitamin K
C. Discontinue heparin and notify the provider
D. Continue therapy and recheck labs
Rationale: This finding suggests heparin-induced thrombocytopenia (HIT),
requiring immediate discontinuation.
9. A nurse is preparing to administer digoxin. Which finding requires
withholding the medication?
A. Apical pulse of 72/min
B. Serum digoxin level 1.2 ng/mL
C. Serum potassium 2.9 mEq/L
D. Blood pressure 110/70 mm Hg
, Rationale: Hypokalemia increases the risk of digoxin toxicity and warrants
holding the medication.
10.A client with diabetes insipidus is receiving desmopressin. Which outcome
indicates therapeutic effectiveness?
A. Increased serum sodium
B. Decreased urine output
C. Increased thirst
D. Weight loss
Rationale: Desmopressin reduces excessive urine output by replacing
antidiuretic hormone.
11.A nurse is caring for a client with a chest tube for pneumothorax. Which
finding requires immediate intervention?
A. Tidaling in the water seal chamber
B. Sudden absence of breath sounds on the affected side
C. Drainage of 50 mL in 4 hours
D. Mild subcutaneous emphysema
Rationale: Sudden loss of breath sounds may indicate tube dislodgement or
worsening pneumothorax.
12.A client with acute pancreatitis reports severe abdominal pain. Which
intervention should the nurse implement?
A. Encourage oral fluids
B. Maintain NPO status
C. Apply heat to the abdomen
D. Place the client supine
Rationale: NPO status reduces pancreatic stimulation and enzyme secretion.
13.A nurse is caring for a client with myasthenia gravis. Which medication
should be readily available at the bedside?
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 respiratory distress syndrome
(ARDS) who is receiving mechanical ventilation. Which intervention is the
priority to improve oxygenation?
A. Suctioning the airway every 2 hours
B. Positioning the client in prone position as prescribed
C. Administering IV fluids aggressively
D. Reducing positive end-expiratory pressure (PEEP)
Rationale: Prone positioning improves ventilation–perfusion matching and
oxygenation in ARDS. Aggressive fluids can worsen pulmonary edema,
suctioning does not address oxygenation directly, and reducing PEEP
decreases alveolar recruitment.
2. A client with chronic kidney disease is prescribed epoetin alfa. Which
outcome indicates the medication is effective?
A. Decreased serum potassium
B. Reduced blood urea nitrogen
C. Increased hemoglobin level
D. Improved urine output
Rationale: Epoetin alfa stimulates erythropoiesis, leading to increased
hemoglobin. It does not directly affect potassium, BUN, or urine output.
3. A nurse is assessing a client with suspected increased intracranial pressure
(ICP). Which finding requires immediate intervention?
A. Headache rated 6/10
, B. Unequal pupil size
C. Restlessness
D. Nausea
Rationale: Unequal pupils indicate possible brain herniation and require
immediate action. Headache, restlessness, and nausea are common but less
acute findings.
4. A client with heart failure is receiving furosemide. Which laboratory value
should the nurse monitor most closely?
A. Sodium
B. Calcium
C. Potassium
D. Glucose
Rationale: Loop diuretics cause potassium loss, increasing the risk for
hypokalemia and dysrhythmias.
5. A nurse is teaching a client with chronic obstructive pulmonary disease
(COPD) about pursed-lip breathing. What is the primary purpose of this
technique?
A. Increase tidal volume
B. Prevent airway collapse during exhalation
C. Decrease oxygen consumption
D. Strengthen respiratory muscles
Rationale: Pursed-lip breathing maintains positive airway pressure,
preventing airway collapse and improving gas exchange.
6. A client is admitted with a diagnosis of septic shock. Which intervention
should the nurse anticipate first?
A. Administration of vasopressors
B. Corticosteroid therapy
, C. Rapid infusion of IV crystalloid fluids
D. Blood transfusion
Rationale: Initial management of septic shock prioritizes rapid fluid
resuscitation to restore perfusion before vasopressors.
7. A nurse is caring for a client with cirrhosis and ascites. Which assessment
finding indicates worsening hepatic encephalopathy?
A. Jaundice
B. Asterixis
C. Abdominal distention
D. Spider angiomas
Rationale: Asterixis (flapping tremor) reflects elevated ammonia levels and
worsening encephalopathy.
8. A client receiving heparin therapy develops a platelet count of 80,000/mm³.
What is the nurse’s priority action?
A. Reduce the heparin dose
B. Administer vitamin K
C. Discontinue heparin and notify the provider
D. Continue therapy and recheck labs
Rationale: This finding suggests heparin-induced thrombocytopenia (HIT),
requiring immediate discontinuation.
9. A nurse is preparing to administer digoxin. Which finding requires
withholding the medication?
A. Apical pulse of 72/min
B. Serum digoxin level 1.2 ng/mL
C. Serum potassium 2.9 mEq/L
D. Blood pressure 110/70 mm Hg
, Rationale: Hypokalemia increases the risk of digoxin toxicity and warrants
holding the medication.
10.A client with diabetes insipidus is receiving desmopressin. Which outcome
indicates therapeutic effectiveness?
A. Increased serum sodium
B. Decreased urine output
C. Increased thirst
D. Weight loss
Rationale: Desmopressin reduces excessive urine output by replacing
antidiuretic hormone.
11.A nurse is caring for a client with a chest tube for pneumothorax. Which
finding requires immediate intervention?
A. Tidaling in the water seal chamber
B. Sudden absence of breath sounds on the affected side
C. Drainage of 50 mL in 4 hours
D. Mild subcutaneous emphysema
Rationale: Sudden loss of breath sounds may indicate tube dislodgement or
worsening pneumothorax.
12.A client with acute pancreatitis reports severe abdominal pain. Which
intervention should the nurse implement?
A. Encourage oral fluids
B. Maintain NPO status
C. Apply heat to the abdomen
D. Place the client supine
Rationale: NPO status reduces pancreatic stimulation and enzyme secretion.
13.A nurse is caring for a client with myasthenia gravis. Which medication
should be readily available at the bedside?
