ATI MEDSURG 2 PRACTICE TEST 2026 FULL
SOLUTION VIEW AHEAD
▶ The nurse admitting a patient to the emergency department on a very
hot summer day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.. Answer: B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
▶ Why does the nurse always ask the client his or her pain level after
taking routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate.
Answer: B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
▶ The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.. Answer: D
,Skin turgor cannot be accurately assessed on an older adult client's hands
because of age-related loss of tissue elasticity in this area. Areas that more
accurately show skin turgor status on an older client include the skin of the
forehead, chest, and abdomen. These should also be assessed, rather
than merely examining dependent body areas. Further assessment is
needed rather than only documenting, monitoring, and notifying the
physician.
▶ The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal. Answer: C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris, urinary
frequency and leakage, and the urge to void continuously while the client
still has the catheter inserted are all considered to be expected
complications of the procedure. They will resolve as the client continues to
recover and the catheter is removed. However, the presence of bright red
blood with clots indicates arterial bleeding and should be reported to the
provider.
▶ 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
SOLUTION VIEW AHEAD
▶ The nurse admitting a patient to the emergency department on a very
hot summer day would suspect hyperthermia when the patient
demonstrates:
A) slow capillary refill.
B) red, sweaty skin.
C) low pulse rate.
D) decreased respirations.. Answer: B
With hyperthermia, vasodilatation occurs causing the skin to appear
flushed and warm or hot to touch. There is an increased respiration rate
with hyperthermia. The heart rate increases with hyperthermia. With
hypothermia there is slow capillary refill.
▶ Why does the nurse always ask the client his or her pain level after
taking routine vital signs?
A) To follow McCaffery's guidelines on pain management
B) To ensure that pain assessment occurs on a regular basis
C) To determine the need for more frequent vital sign measurement
D) To determine whether pain is influencing blood pressure and heart rate.
Answer: B
Making pain the fifth vital sign allows more frequent and accurate
assessment, which can contribute to better pain management.
▶ The nurse observes skin tenting on the back of the older adult client's
hand. Which action by the nurse is most appropriate?
A) Examine dependent body areas.
B) Notify the physician.
C) Document the finding and continue to monitor.
D) Assess turgor on the client's forehead.. Answer: D
,Skin turgor cannot be accurately assessed on an older adult client's hands
because of age-related loss of tissue elasticity in this area. Areas that more
accurately show skin turgor status on an older client include the skin of the
forehead, chest, and abdomen. These should also be assessed, rather
than merely examining dependent body areas. Further assessment is
needed rather than only documenting, monitoring, and notifying the
physician.
▶ The nurse is assessing a client who has undergone a transurethral
resection of the prostate (TURP). Which assessment finding requires
immediate action by the nurse?
A) Having the urge to void continuously while the catheter is inserted
B) Passing small blood clots after catheter removal
C) Having bright red drainage with multiple blood clots
D) Experiencing urinary frequency after catheter removal. Answer: C
A client who undergoes a TURP is at risk for bleeding during the first 24
hours after surgery. Passage of small blood clots and tissue debris, urinary
frequency and leakage, and the urge to void continuously while the client
still has the catheter inserted are all considered to be expected
complications of the procedure. They will resolve as the client continues to
recover and the catheter is removed. However, the presence of bright red
blood with clots indicates arterial bleeding and should be reported to the
provider.
▶ 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
