ATI MED SURG PROCTORED EXAM NEXT GENERATION LATEST
VERSION 2026-2027 EXAM WITH ACTUAL TEST BANK 214
QUESTION AND CORRECT DETAILED ANSWERS WITH
RATIONALES.RATED FIVE STARS.
A charge nurse making rounds observes that an assistive personnel (AP) has
applied wrist restraints to a client who is agitated and does not have a
prescription for restraints. Which of the following actions should the nurse
take first?
A) Inform the unit manager of the incident
B) Review the chart for nonrestraint alternatives for agitation
C) Remove the restraints from the client's wrists
D) Speak with the AP about the incident
Correct Answer: C
Rationale
The nurse's priority action is to remove the restraints from the client's wrists
immediately, as the AP applied restraints without a prescription, which
violates facility policy and client rights. Restraints should only be applied
with a valid prescription and after less restrictive interventions have been
attempted. Option A is incorrect because while the unit manager should be
informed, immediate client safety is the priority. Option B is incorrect
because reviewing alternatives should occur before considering restraints,
but the immediate action is removal. Option D is incorrect because speaking
with the AP should occur after the client's safety has been addressed.
DIF: Cognitive Level: Apply (Application)
TOP: Restraint Use and Client Safety
MSC: Safe and Effective Care Environment/Management of Care
,A charge nurse notices that two staff nurses are not taking meal breaks
during their shifts. Which of the following actions should the nurse take
first?
A) Provide coverage for the nurses' breaks
B) Review facility policies for taking scheduled breaks
C) Determine the reasons the nurses are not taking scheduled breaks
D) Discuss time management strategies with the nurses
Correct Answer: C
Rationale
The nurse should first determine the reasons the nurses are not taking
scheduled breaks to identify underlying causes and develop appropriate
interventions. Understanding the root cause is essential before
implementing solutions. Option A is incorrect because providing coverage
should occur after determining the reasons for missed breaks. Option B is
incorrect because reviewing policies is important but should follow
assessment of the situation. Option D is incorrect because discussing time
management strategies should occur after identifying the specific barriers to
taking breaks.
DIF: Cognitive Level: Apply (Application)
TOP: Staff Management and Delegation
MSC: Safe and Effective Care Environment/Management of Care
A client has a new permanent pacemaker inserted. Which of the following
home care instructions should the nurse include?
A) Regular programming evaluations can be conducted by telephone
B) The client should avoid using remote control devices to prevent
dysrhythmias
C) The client should avoid using a microwave oven to heat food
D) Swimming could cause the unit to have an electrical short
,Correct Answer: A
Rationale
Clients with permanent pacemakers can have their devices evaluated
remotely via telephone or internet-based monitoring systems. These
evaluations are an important part of ongoing care and can detect battery
depletion or lead issues. Option B is incorrect because remote control
devices, such as television remotes, do not interfere with pacemaker
function. Option C is incorrect because modern microwave ovens are well-
shielded and do not interfere with pacemakers. Option D is incorrect
because swimming is generally not contraindicated; however, the client
should avoid submersion until cleared by the provider.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Pacemaker Home Care
MSC: Health Promotion and Maintenance
A nurse manager is reviewing isolation guidelines with a newly licensed
nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A) "I will use an alcohol-based hand cleanser when caring for a client who
has C. difficile."
B) "I will wear a cover gown when caring for a client who has herpes
simplex."
C) "I will wear an N95 respirator mask when caring for a client who is on
contact precautions."
D) "I will place a client who requires protective isolation in a negative airflow
room."
Correct Answer: B
Rationale
Herpes simplex virus is transmitted via direct contact with infected lesions or
, secretions, requiring contact precautions, which include wearing a gown and
gloves. Option A is incorrect because alcohol-based hand sanitizers are not
effective against C. difficile spores; hand washing with soap and water is
required. Option C is incorrect because N95 respirators are used for airborne
precautions, not contact precautions. Option D is incorrect because
protective isolation does not require negative airflow; that is used for
airborne precautions.
DIF: Cognitive Level: Evaluate (Evaluation)
TOP: Infection Control and Isolation Precautions
MSC: Safe and Effective Care Environment/Safety and Infection Control
A staff nurse is supervising a newly licensed nurse who is preparing to
administer an intermittent tube feeding to a client. Which of the following
actions by the newly licensed nurse is appropriate?
A) Adding colored food dye to the formula
B) Flushing the tube with 15 mL of water
C) Elevating the head of the bed to a 20-degree angle
D) Checking residual volume before each feeding
Correct Answer: D
Rationale
Checking residual volume before each feeding is an appropriate action to
assess gastric emptying and prevent complications such as aspiration. Option
A is incorrect because adding food dye to enteral formula is not
recommended and has been associated with adverse effects. Option B is
incorrect because the tube should be flushed with 30 to 50 mL of water
before and after feedings, not 15 mL. Option C is incorrect because the head
of the bed should be elevated to 30 to 45 degrees during feedings to prevent
aspiration.
VERSION 2026-2027 EXAM WITH ACTUAL TEST BANK 214
QUESTION AND CORRECT DETAILED ANSWERS WITH
RATIONALES.RATED FIVE STARS.
A charge nurse making rounds observes that an assistive personnel (AP) has
applied wrist restraints to a client who is agitated and does not have a
prescription for restraints. Which of the following actions should the nurse
take first?
A) Inform the unit manager of the incident
B) Review the chart for nonrestraint alternatives for agitation
C) Remove the restraints from the client's wrists
D) Speak with the AP about the incident
Correct Answer: C
Rationale
The nurse's priority action is to remove the restraints from the client's wrists
immediately, as the AP applied restraints without a prescription, which
violates facility policy and client rights. Restraints should only be applied
with a valid prescription and after less restrictive interventions have been
attempted. Option A is incorrect because while the unit manager should be
informed, immediate client safety is the priority. Option B is incorrect
because reviewing alternatives should occur before considering restraints,
but the immediate action is removal. Option D is incorrect because speaking
with the AP should occur after the client's safety has been addressed.
DIF: Cognitive Level: Apply (Application)
TOP: Restraint Use and Client Safety
MSC: Safe and Effective Care Environment/Management of Care
,A charge nurse notices that two staff nurses are not taking meal breaks
during their shifts. Which of the following actions should the nurse take
first?
A) Provide coverage for the nurses' breaks
B) Review facility policies for taking scheduled breaks
C) Determine the reasons the nurses are not taking scheduled breaks
D) Discuss time management strategies with the nurses
Correct Answer: C
Rationale
The nurse should first determine the reasons the nurses are not taking
scheduled breaks to identify underlying causes and develop appropriate
interventions. Understanding the root cause is essential before
implementing solutions. Option A is incorrect because providing coverage
should occur after determining the reasons for missed breaks. Option B is
incorrect because reviewing policies is important but should follow
assessment of the situation. Option D is incorrect because discussing time
management strategies should occur after identifying the specific barriers to
taking breaks.
DIF: Cognitive Level: Apply (Application)
TOP: Staff Management and Delegation
MSC: Safe and Effective Care Environment/Management of Care
A client has a new permanent pacemaker inserted. Which of the following
home care instructions should the nurse include?
A) Regular programming evaluations can be conducted by telephone
B) The client should avoid using remote control devices to prevent
dysrhythmias
C) The client should avoid using a microwave oven to heat food
D) Swimming could cause the unit to have an electrical short
,Correct Answer: A
Rationale
Clients with permanent pacemakers can have their devices evaluated
remotely via telephone or internet-based monitoring systems. These
evaluations are an important part of ongoing care and can detect battery
depletion or lead issues. Option B is incorrect because remote control
devices, such as television remotes, do not interfere with pacemaker
function. Option C is incorrect because modern microwave ovens are well-
shielded and do not interfere with pacemakers. Option D is incorrect
because swimming is generally not contraindicated; however, the client
should avoid submersion until cleared by the provider.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Pacemaker Home Care
MSC: Health Promotion and Maintenance
A nurse manager is reviewing isolation guidelines with a newly licensed
nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A) "I will use an alcohol-based hand cleanser when caring for a client who
has C. difficile."
B) "I will wear a cover gown when caring for a client who has herpes
simplex."
C) "I will wear an N95 respirator mask when caring for a client who is on
contact precautions."
D) "I will place a client who requires protective isolation in a negative airflow
room."
Correct Answer: B
Rationale
Herpes simplex virus is transmitted via direct contact with infected lesions or
, secretions, requiring contact precautions, which include wearing a gown and
gloves. Option A is incorrect because alcohol-based hand sanitizers are not
effective against C. difficile spores; hand washing with soap and water is
required. Option C is incorrect because N95 respirators are used for airborne
precautions, not contact precautions. Option D is incorrect because
protective isolation does not require negative airflow; that is used for
airborne precautions.
DIF: Cognitive Level: Evaluate (Evaluation)
TOP: Infection Control and Isolation Precautions
MSC: Safe and Effective Care Environment/Safety and Infection Control
A staff nurse is supervising a newly licensed nurse who is preparing to
administer an intermittent tube feeding to a client. Which of the following
actions by the newly licensed nurse is appropriate?
A) Adding colored food dye to the formula
B) Flushing the tube with 15 mL of water
C) Elevating the head of the bed to a 20-degree angle
D) Checking residual volume before each feeding
Correct Answer: D
Rationale
Checking residual volume before each feeding is an appropriate action to
assess gastric emptying and prevent complications such as aspiration. Option
A is incorrect because adding food dye to enteral formula is not
recommended and has been associated with adverse effects. Option B is
incorrect because the tube should be flushed with 30 to 50 mL of water
before and after feedings, not 15 mL. Option C is incorrect because the head
of the bed should be elevated to 30 to 45 degrees during feedings to prevent
aspiration.
