ATI MEDSURG 2 BUNDLED EXAMS 2026
COMPLETE QUESTIONS AND ANSWERS
▶ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin. Answer: C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility, the
one with the greatest potential impact is being immune compromised.
▶ The nurse is assessing a client with an early onset of multiple sclerosis
(MS). Which clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance. Answer: A
Early signs and symptoms of MS include changes in motor skills, vision,
and sensation. The other manifestations are later signs of MS.
▶ The nurse determines that a client has a Braden Scale score of 9. Which
is the nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol.. Answer: B
A score of 11 or less on the Braden Scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear. The nurse needs to
,consult with the health care provider to relay this information and to obtain
more aggressive skin protection measures than are currently provided.
▶ While planning care for a patient experiencing fatigue due to
chemotherapy, which of the following is the most appropriate nursing
intervention?
A) Completing all nursing care in the evening when the patient is more
rested
B) Completing all nursing care in the morning so the patient can rest the
remainder of the day
C) Limiting visitors, thus promoting the maximal amount of hours for sleep
D) Prioritization and administration of nursing care throughout the day.
Answer: D
Pacing activities throughout the day conserves energy, and nursing care
should be paced as well. Fatigue is a common side effect of cancer and
treatment; and while adequate sleep is important, an increase in the
number of hours slept will not resolve the fatigue. Restriction of visitors
does not promote healthy coping and can result in feelings of isolation.
▶ A diabetic client has numbness and reduced sensation. Which
intervention does the nurse teach this client to prevent injury?
A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror."
C) "Wear white socks instead of colored socks."
D) "Rotate your insulin injection sites.". Answer: A
Clients with diminished sensory perception can easily experience a burn
injury when bath water is too hot. Instead of checking the temperature of
the water by feeling it, they should use a thermometer. Examining the feet
daily does not prevent injury, although daily foot examinations are
important to find problems so they can be addressed. Rotating insulin and
wearing white socks also will not prevent injury.
▶ Which client does the nurse assess to be at greatest risk for pressure
ulcer development?
A) Client who requires assistance with ambulation
,B) Incontinent client with limited mobility
C) Client with hypertension on multiple medications
D) Client who has pneumonia. Answer: B
Being immobile and being incontinent are two significant risk factors for the
development of pressure ulcers. Clients with pneumonia and hypertension
do not have specific risk factors. The client who needs assistance with
ambulation might be at moderate risk if he or she does not move about
much, but having two risk factors makes the last option the person at
highest risk.
▶ The nurse is instructing the nursing assistant to prevent pressure ulcers
in a frail older patient; the nursing assistant understands the instruction
when she agrees to:
A) bathe and dry the skin vigorously to stimulate circulation.
B) limit intake of fluid and offer frequent snacks.
C) turn the patient at least every 2 hours.
D) keep the head of the bed elevated 30 degrees.. Answer: C
The patient should be turned at least every 2 hours as permanent damage
can occur in 2 hours or less. If skin assessment reveals a stage I ulcer
while on a 2-hour turning schedule, the patient must be turned more
frequently. Limiting fluids will prevent healing; however, offering snacks is
indicated to increase healing particularly if they are protein based, because
protein plays a role in healing. Use of doughnuts, elevated heads of beds,
and overstimulation of skin may all stimulate, if not actually encourage,
dermal decline.
▶ The client with type 2 diabetes has recently been changed from the oral
antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to
glyburide-metformin (Glucovance). The nurse includes which information in
the teaching about this medication?
A) "Glucovance is more effective than glyburide and metformin."
B) "Your diabetes is improving and you now need only one drug."
C) "Glucovance contains a combination of glyburide and metformin."
D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic
agents.". Answer: C
, Glucovance is composed of glyburide and metformin. It is given to enhance
the convenience of antidiabetic therapy with glyburide and metformin. The
other statements are not accurate.
▶ The nurse administers 6 units of regular insulin and 10 units NPH insulin
at 7 AM. At what time does the nurse assess the client for problems related
to the NPH insulin?
A) 4 PM
B) 11 PM
C) 8 AM
D) 8 PM. Answer: A
NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4
to 12 hours, and duration of action of 22 hours. Checking the client at 8:00
AM would be too soon; 8:00 PM and 11:00 PM would be too late.
▶ The nurse is caring for a client who is immobile from a recent stroke.
Which intervention does the nurse implement to prevent complications in
this client?
A) Teach the client to touch and use both sides of the body.
B) Apply sequential compression stockings.
C) Instruct the client to turn the head from side to side.
D) Position the client with the unaffected side down.. Answer: B
To avoid complications of immobility, such as deep vein thrombosis, the
nurse applies sequential compression stockings or pneumatic compression
boots. Efforts are made to mobilize the client as much as possible, and the
client should be repositioned frequently. The other interventions will not
prevent complications of immobility.
▶ The nurse is caring for a client who has experienced a stroke. Which
nursing intervention for nutrition does the nurse implement to prevent
complications from cranial nerve IX impairment?
A) Place the client in high Fowler's position.
B) Verbalize the placement of food on the client's plate.
C) Order a clear liquid diet for the client.
D) Turn the client's plate around halfway through the meal.. Answer: A
COMPLETE QUESTIONS AND ANSWERS
▶ Which finding puts a client at greatest risk for wound infection?
A) Presence of a deep wound
B) Coexisting medical conditions
C) Immune compromised status
D) Severely reddened skin. Answer: C
A compromised immune system puts a client at greatest risk for infection.
Although all the other options might increase the client's susceptibility, the
one with the greatest potential impact is being immune compromised.
▶ The nurse is assessing a client with an early onset of multiple sclerosis
(MS). Which clinical manifestations does the nurse expect to see?
A) Nystagmus & Diplopia
B) Hyperresponsive reflexes
C) Excessive somnolence
D) Heat intolerance. Answer: A
Early signs and symptoms of MS include changes in motor skills, vision,
and sensation. The other manifestations are later signs of MS.
▶ The nurse determines that a client has a Braden Scale score of 9. Which
is the nurse's best intervention related to this assessment?
A) Increase the client's fluid intake.
B) Consult with the health care provider.
C) Reassess the client in 3 days.
D) Document the finding per protocol.. Answer: B
A score of 11 or less on the Braden Scale indicates severe risk for pressure
ulcer development in terms of decreased sensory perception, exposure to
moisture, decreased independent activity, decreased mobility, poor
nutrition, and chronic exposure to friction and shear. The nurse needs to
,consult with the health care provider to relay this information and to obtain
more aggressive skin protection measures than are currently provided.
▶ While planning care for a patient experiencing fatigue due to
chemotherapy, which of the following is the most appropriate nursing
intervention?
A) Completing all nursing care in the evening when the patient is more
rested
B) Completing all nursing care in the morning so the patient can rest the
remainder of the day
C) Limiting visitors, thus promoting the maximal amount of hours for sleep
D) Prioritization and administration of nursing care throughout the day.
Answer: D
Pacing activities throughout the day conserves energy, and nursing care
should be paced as well. Fatigue is a common side effect of cancer and
treatment; and while adequate sleep is important, an increase in the
number of hours slept will not resolve the fatigue. Restriction of visitors
does not promote healthy coping and can result in feelings of isolation.
▶ A diabetic client has numbness and reduced sensation. Which
intervention does the nurse teach this client to prevent injury?
A) "Use a bath thermometer to test the water temperature."
B) "Examine your feet daily using a mirror."
C) "Wear white socks instead of colored socks."
D) "Rotate your insulin injection sites.". Answer: A
Clients with diminished sensory perception can easily experience a burn
injury when bath water is too hot. Instead of checking the temperature of
the water by feeling it, they should use a thermometer. Examining the feet
daily does not prevent injury, although daily foot examinations are
important to find problems so they can be addressed. Rotating insulin and
wearing white socks also will not prevent injury.
▶ Which client does the nurse assess to be at greatest risk for pressure
ulcer development?
A) Client who requires assistance with ambulation
,B) Incontinent client with limited mobility
C) Client with hypertension on multiple medications
D) Client who has pneumonia. Answer: B
Being immobile and being incontinent are two significant risk factors for the
development of pressure ulcers. Clients with pneumonia and hypertension
do not have specific risk factors. The client who needs assistance with
ambulation might be at moderate risk if he or she does not move about
much, but having two risk factors makes the last option the person at
highest risk.
▶ The nurse is instructing the nursing assistant to prevent pressure ulcers
in a frail older patient; the nursing assistant understands the instruction
when she agrees to:
A) bathe and dry the skin vigorously to stimulate circulation.
B) limit intake of fluid and offer frequent snacks.
C) turn the patient at least every 2 hours.
D) keep the head of the bed elevated 30 degrees.. Answer: C
The patient should be turned at least every 2 hours as permanent damage
can occur in 2 hours or less. If skin assessment reveals a stage I ulcer
while on a 2-hour turning schedule, the patient must be turned more
frequently. Limiting fluids will prevent healing; however, offering snacks is
indicated to increase healing particularly if they are protein based, because
protein plays a role in healing. Use of doughnuts, elevated heads of beds,
and overstimulation of skin may all stimulate, if not actually encourage,
dermal decline.
▶ The client with type 2 diabetes has recently been changed from the oral
antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to
glyburide-metformin (Glucovance). The nurse includes which information in
the teaching about this medication?
A) "Glucovance is more effective than glyburide and metformin."
B) "Your diabetes is improving and you now need only one drug."
C) "Glucovance contains a combination of glyburide and metformin."
D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic
agents.". Answer: C
, Glucovance is composed of glyburide and metformin. It is given to enhance
the convenience of antidiabetic therapy with glyburide and metformin. The
other statements are not accurate.
▶ The nurse administers 6 units of regular insulin and 10 units NPH insulin
at 7 AM. At what time does the nurse assess the client for problems related
to the NPH insulin?
A) 4 PM
B) 11 PM
C) 8 AM
D) 8 PM. Answer: A
NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4
to 12 hours, and duration of action of 22 hours. Checking the client at 8:00
AM would be too soon; 8:00 PM and 11:00 PM would be too late.
▶ The nurse is caring for a client who is immobile from a recent stroke.
Which intervention does the nurse implement to prevent complications in
this client?
A) Teach the client to touch and use both sides of the body.
B) Apply sequential compression stockings.
C) Instruct the client to turn the head from side to side.
D) Position the client with the unaffected side down.. Answer: B
To avoid complications of immobility, such as deep vein thrombosis, the
nurse applies sequential compression stockings or pneumatic compression
boots. Efforts are made to mobilize the client as much as possible, and the
client should be repositioned frequently. The other interventions will not
prevent complications of immobility.
▶ The nurse is caring for a client who has experienced a stroke. Which
nursing intervention for nutrition does the nurse implement to prevent
complications from cranial nerve IX impairment?
A) Place the client in high Fowler's position.
B) Verbalize the placement of food on the client's plate.
C) Order a clear liquid diet for the client.
D) Turn the client's plate around halfway through the meal.. Answer: A
