**Exam Title:** ATI Med-Surg II (Medical-Surgical
Nursing 2) – Nursing Program – Exam-Style Questions
with Detailed Rationales (A Grade)
**Length:** 85 questions
---
**1. A client with cirrhosis of the liver develops ascites and shortness of breath. Which intervention
should the nurse prioritize?**
A) Restrict dietary protein
B) Administer spironolactone as prescribed
C) Position the client in semi-Fowler’s with head of bed elevated
D) Measure abdominal girth daily
💡 **RATIONALE** – The priority is airway and breathing. Semi-Fowler’s position elevates the
diaphragm, improving lung expansion and reducing dyspnea from ascites. Spironolactone helps but is
not the first action.
✔️ **ANSWER** – C) Position the client in semi-Fowler’s with head of bed elevated
---
**2. A client with heart failure is receiving furosemide 40 mg IV push. Which finding requires
immediate action?**
A) Urine output of 200 mL in 2 hours
B) Serum potassium of 3.2 mEq/L
C) Blood pressure of 110/70 mmHg
D) Weight loss of 2 kg in 24 hours
,💡 **RATIONALE** – Severe hypokalemia (<3.5) from furosemide can cause life-threatening
arrhythmias. This requires immediate potassium replacement and possibly holding the next dose.
✔️ **ANSWER** – B) Serum potassium of 3.2 mEq/L
---
**3. A client with type 2 diabetes mellitus is admitted with a blood glucose of 650 mg/dL, serum
osmolality 320 mOsm/kg, and no ketones in the urine. Which condition is this?**
A) Diabetic ketoacidosis (DKA)
B) Hyperosmolar hyperglycemic state (HHS)
C) Hypoglycemia
D) Lactic acidosis
💡 **RATIONALE** – HHS presents with severe hyperglycemia (>600), hyperosmolality, no or minimal
ketones, and occurs in type 2 diabetes. DKA has ketones and acidosis.
✔️ **ANSWER** – B) Hyperosmolar hyperglycemic state (HHS)
---
**4. A client with chronic kidney disease (CKD) stage 4 has a hemoglobin of 7.8 g/dL. Which
medication does the nurse expect to be prescribed?**
A) Ferrous sulfate orally
B) Erythropoietin (Epogen, Procrit) subcutaneously
C) Folic acid 1 mg daily
D) Vitamin B12 injection monthly
💡 **RATIONALE** – CKD causes erythropoietin deficiency. Recombinant erythropoietin (EPO)
stimulates RBC production. Iron may be added but EPO is the primary treatment for anemia of CKD.
✔️ **ANSWER** – B) Erythropoietin (Epogen, Procrit) subcutaneously
,---
**5. A client is 2 hours post-hip replacement surgery. Which nursing action is most important to
prevent dislocation?**
A) Keep the client on bed rest for 24 hours
B) Place an abduction pillow between the legs
C) Turn the client only to the operative side
D) Flex the hip to 120 degrees during repositioning
💡 **RATIONALE** – An abduction pillow keeps the hip in neutral position, preventing adduction and
flexion >90 degrees, which can dislocate the prosthesis.
✔️ **ANSWER** – B) Place an abduction pillow between the legs
---
**6. A client with pneumonia has a respiratory rate of 32, oxygen saturation of 88% on room air, and
confusion. The nurse should first:**
A) Apply oxygen at 2 L/min via nasal cannula
B) Position the client supine
C) Notify the provider
D) Obtain a sputum culture
💡 **RATIONALE** – ABCs: hypoxia with altered mental status requires immediate oxygen. SpO2
<90% is critical. After oxygen, reassess and notify provider.
✔️ **ANSWER** – A) Apply oxygen at 2 L/min via nasal cannula
---
**7. A client with ulcerative colitis is prescribed sulfasalazine. Which instruction should the nurse
include?**
, A) Take on an empty stomach
B) Increase fluid intake to prevent crystalluria
C) Stop taking if urine turns orange-yellow
D) Use a soft toothbrush to prevent bleeding
💡 **RATIONALE** – Sulfasalazine can cause crystalluria and kidney damage. Adequate fluid intake
(2–3 L/day) helps prevent this. Orange-yellow urine is a harmless side effect.
✔️ **ANSWER** – B) Increase fluid intake to prevent crystalluria
---
**8. A client with myasthenia gravis is admitted with difficulty swallowing and drooling. Which
complication is the nurse most concerned about?**
A) Dehydration
B) Aspiration pneumonia
C) Myasthenic crisis
D) Cholinergic crisis
💡 **RATIONALE** – Dysphagia and drooling increase aspiration risk. Aspiration pneumonia is a life-
threatening complication. The nurse should maintain airway and consider NPO status.
✔️ **ANSWER** – B) Aspiration pneumonia
---
**9. A client with acute pancreatitis has a nasogastric (NG) tube to low intermittent suction. Which
lab finding is most concerning?**
A) Serum amylase 400 U/L
B) Serum lipase 600 U/L
C) Serum calcium 6.8 mg/dL (normal 8.5–10.2)
D) White blood cell count 15,000/mm³
Nursing 2) – Nursing Program – Exam-Style Questions
with Detailed Rationales (A Grade)
**Length:** 85 questions
---
**1. A client with cirrhosis of the liver develops ascites and shortness of breath. Which intervention
should the nurse prioritize?**
A) Restrict dietary protein
B) Administer spironolactone as prescribed
C) Position the client in semi-Fowler’s with head of bed elevated
D) Measure abdominal girth daily
💡 **RATIONALE** – The priority is airway and breathing. Semi-Fowler’s position elevates the
diaphragm, improving lung expansion and reducing dyspnea from ascites. Spironolactone helps but is
not the first action.
✔️ **ANSWER** – C) Position the client in semi-Fowler’s with head of bed elevated
---
**2. A client with heart failure is receiving furosemide 40 mg IV push. Which finding requires
immediate action?**
A) Urine output of 200 mL in 2 hours
B) Serum potassium of 3.2 mEq/L
C) Blood pressure of 110/70 mmHg
D) Weight loss of 2 kg in 24 hours
,💡 **RATIONALE** – Severe hypokalemia (<3.5) from furosemide can cause life-threatening
arrhythmias. This requires immediate potassium replacement and possibly holding the next dose.
✔️ **ANSWER** – B) Serum potassium of 3.2 mEq/L
---
**3. A client with type 2 diabetes mellitus is admitted with a blood glucose of 650 mg/dL, serum
osmolality 320 mOsm/kg, and no ketones in the urine. Which condition is this?**
A) Diabetic ketoacidosis (DKA)
B) Hyperosmolar hyperglycemic state (HHS)
C) Hypoglycemia
D) Lactic acidosis
💡 **RATIONALE** – HHS presents with severe hyperglycemia (>600), hyperosmolality, no or minimal
ketones, and occurs in type 2 diabetes. DKA has ketones and acidosis.
✔️ **ANSWER** – B) Hyperosmolar hyperglycemic state (HHS)
---
**4. A client with chronic kidney disease (CKD) stage 4 has a hemoglobin of 7.8 g/dL. Which
medication does the nurse expect to be prescribed?**
A) Ferrous sulfate orally
B) Erythropoietin (Epogen, Procrit) subcutaneously
C) Folic acid 1 mg daily
D) Vitamin B12 injection monthly
💡 **RATIONALE** – CKD causes erythropoietin deficiency. Recombinant erythropoietin (EPO)
stimulates RBC production. Iron may be added but EPO is the primary treatment for anemia of CKD.
✔️ **ANSWER** – B) Erythropoietin (Epogen, Procrit) subcutaneously
,---
**5. A client is 2 hours post-hip replacement surgery. Which nursing action is most important to
prevent dislocation?**
A) Keep the client on bed rest for 24 hours
B) Place an abduction pillow between the legs
C) Turn the client only to the operative side
D) Flex the hip to 120 degrees during repositioning
💡 **RATIONALE** – An abduction pillow keeps the hip in neutral position, preventing adduction and
flexion >90 degrees, which can dislocate the prosthesis.
✔️ **ANSWER** – B) Place an abduction pillow between the legs
---
**6. A client with pneumonia has a respiratory rate of 32, oxygen saturation of 88% on room air, and
confusion. The nurse should first:**
A) Apply oxygen at 2 L/min via nasal cannula
B) Position the client supine
C) Notify the provider
D) Obtain a sputum culture
💡 **RATIONALE** – ABCs: hypoxia with altered mental status requires immediate oxygen. SpO2
<90% is critical. After oxygen, reassess and notify provider.
✔️ **ANSWER** – A) Apply oxygen at 2 L/min via nasal cannula
---
**7. A client with ulcerative colitis is prescribed sulfasalazine. Which instruction should the nurse
include?**
, A) Take on an empty stomach
B) Increase fluid intake to prevent crystalluria
C) Stop taking if urine turns orange-yellow
D) Use a soft toothbrush to prevent bleeding
💡 **RATIONALE** – Sulfasalazine can cause crystalluria and kidney damage. Adequate fluid intake
(2–3 L/day) helps prevent this. Orange-yellow urine is a harmless side effect.
✔️ **ANSWER** – B) Increase fluid intake to prevent crystalluria
---
**8. A client with myasthenia gravis is admitted with difficulty swallowing and drooling. Which
complication is the nurse most concerned about?**
A) Dehydration
B) Aspiration pneumonia
C) Myasthenic crisis
D) Cholinergic crisis
💡 **RATIONALE** – Dysphagia and drooling increase aspiration risk. Aspiration pneumonia is a life-
threatening complication. The nurse should maintain airway and consider NPO status.
✔️ **ANSWER** – B) Aspiration pneumonia
---
**9. A client with acute pancreatitis has a nasogastric (NG) tube to low intermittent suction. Which
lab finding is most concerning?**
A) Serum amylase 400 U/L
B) Serum lipase 600 U/L
C) Serum calcium 6.8 mg/dL (normal 8.5–10.2)
D) White blood cell count 15,000/mm³
