ATI MED SURG PRCTORED VERSION A,B,C
EXAM ACTUAL QUESTION AND ANSWERS
LATEST UPDATE 2027-2024 RATED A GRADE.
.
MULTIPLE CHOICE
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding
will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
✔️ Correct Answer: C
Rationale:
When a patient experiences shaking chills, the body is generating heat through muscle contractions to
raise the core temperature (Option C). This is the body's response to a pyrogen-induced resetting of the
hypothalamic set point during a systemic infection. The chills are followed by a rising body temperature
as the body attempts to reach the new set point. The nurse should monitor the patient's temperature
and provide comfort measures.
Option A is incorrect because skin flushing typically occurs during the febrile phase, not immediately
after chills. Option B is incorrect because muscle cramps are not the primary expected finding. Option D
is incorrect because blood pressure typically increases, not decreases, with fever.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of
101.8°F (38.7°C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket
b. Notify the health care provider
,c. Give the prescribed PRN aspirin 650 mg
d. Check the patient's oral temperature again in 4 hours
✔️ Correct Answer: D
Rationale:
The nurse should recheck the patient's temperature in 4 hours (Option D). A temperature of 101.8°F in a
young adult receiving antibiotics is expected and indicates the body is fighting the infection. The nurse
should monitor the temperature and assess the patient's response to antibiotics. Antipyretics may be
given if the patient is uncomfortable, but immediate action is not required unless the temperature is
extremely high or the patient is in distress.
Option A is incorrect because a cooling blanket is not indicated for a moderate fever. Option B is
incorrect because this temperature is not a critical finding requiring immediate notification. Option C is
incorrect while aspirin may be given if prescribed, it is not the most appropriate first action.
A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by
yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing
✔️ Correct Answer: C
Rationale:
A hydrocolloid dressing (DuoDerm) should be applied to this wound (Option C). The presence of black
(necrotic) tissue and yellow-green semiliquid material (slough) indicates a wound that requires
debridement and moisture-retentive therapy. Hydrocolloid dressings provide a moist environment that
promotes autolytic debridement, which helps remove necrotic tissue and slough. This dressing is
appropriate for wounds with moderate to heavy drainage.
Option A is incorrect because dry gauze dressings do not provide a moist healing environment. Option B
is incorrect because nonadherent dressings are used for clean wounds. Option D is incorrect because
transparent film dressings are used for clean, dry wounds.
,A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How
would the nurse document this wound?
a. Red wound
b. Yellow wound
c. Full-thickness wound
d. Stage III pressure ulcer
✔️ Correct Answer: A
Rationale:
The nurse should document this wound as a red wound (Option A). Red wounds contain healthy
granulation tissue, which is deep pink to bright red in color. Granulation tissue indicates the wound is
healing properly. The wound appears red and is actively forming new tissue. Red wounds require
protection and a moist environment to promote healing.
Option B is incorrect because yellow wounds contain slough (yellow or yellow-green tissue) and require
debridement. Option C is incorrect because full-thickness describes the depth of the wound, not the
color. Option D is incorrect because Stage III pressure ulcer refers to a specific depth category, not the
appearance of granulation tissue.
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action
is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell count
b. Check the skin for areas of redness
c. Check the temperature every 2 hours
d. Ask about fatigue or feelings of malaise
✔️ Correct Answer: D
Rationale:
The nurse should ask about fatigue or feelings of malaise (Option D). Corticosteroids suppress the
immune system and mask typical signs of infection such as fever and inflammation. Early signs of
infection in patients on corticosteroids may include vague symptoms such as fatigue, malaise, and subtle
changes in condition. The nurse should assess for these non-specific symptoms to detect infection early.
Option A is incorrect because corticosteroids can mask leukocytosis; WBC count may not be elevated.
Option B is incorrect because corticosteroids may mask inflammation and redness. Option C is incorrect
while temperature monitoring is important, corticosteroids can mask fever.
, The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
✔️ Correct Answer: D
Rationale:
A wet-to-dry dressing should be used for a patient with a wound that has purulent drainage and dry
brown areas (Option D). Wet-to-dry dressings are used for mechanical debridement of wounds with
necrotic tissue, slough, or purulent drainage. The wet gauze is placed in the wound, allowed to dry, and
then removed, which debrides the wound of dead tissue and debris.
Option A is incorrect because wet-to-dry dressings are not used on wounds with healthy granulation
tissue. Option B is incorrect because approximated surgical incisions require clean, dry dressings. Option
C is incorrect because full-thickness burns require specialized burn dressings.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base
of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure
ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
✔️ Correct Answer: C
Rationale:
This pressure ulcer should be classified as Stage III (Option C). A Stage III pressure ulcer involves full-
thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer extends into, but not
through, the underlying fascia. The wound base may be yellow (slough) and may have undermining or
tunneling. Subcutaneous tissue involvement is characteristic of Stage III ulcers.
Option A is incorrect because Stage I ulcers are non-blanchable erythema on intact skin. Option B is
incorrect because Stage II ulcers are partial-thickness with damage to epidermis and dermis. Option D is
incorrect because Stage IV ulcers involve damage to muscle, bone, or supporting structures.
EXAM ACTUAL QUESTION AND ANSWERS
LATEST UPDATE 2027-2024 RATED A GRADE.
.
MULTIPLE CHOICE
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding
will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
✔️ Correct Answer: C
Rationale:
When a patient experiences shaking chills, the body is generating heat through muscle contractions to
raise the core temperature (Option C). This is the body's response to a pyrogen-induced resetting of the
hypothalamic set point during a systemic infection. The chills are followed by a rising body temperature
as the body attempts to reach the new set point. The nurse should monitor the patient's temperature
and provide comfort measures.
Option A is incorrect because skin flushing typically occurs during the febrile phase, not immediately
after chills. Option B is incorrect because muscle cramps are not the primary expected finding. Option D
is incorrect because blood pressure typically increases, not decreases, with fever.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of
101.8°F (38.7°C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket
b. Notify the health care provider
,c. Give the prescribed PRN aspirin 650 mg
d. Check the patient's oral temperature again in 4 hours
✔️ Correct Answer: D
Rationale:
The nurse should recheck the patient's temperature in 4 hours (Option D). A temperature of 101.8°F in a
young adult receiving antibiotics is expected and indicates the body is fighting the infection. The nurse
should monitor the temperature and assess the patient's response to antibiotics. Antipyretics may be
given if the patient is uncomfortable, but immediate action is not required unless the temperature is
extremely high or the patient is in distress.
Option A is incorrect because a cooling blanket is not indicated for a moderate fever. Option B is
incorrect because this temperature is not a critical finding requiring immediate notification. Option C is
incorrect while aspirin may be given if prescribed, it is not the most appropriate first action.
A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by
yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing
✔️ Correct Answer: C
Rationale:
A hydrocolloid dressing (DuoDerm) should be applied to this wound (Option C). The presence of black
(necrotic) tissue and yellow-green semiliquid material (slough) indicates a wound that requires
debridement and moisture-retentive therapy. Hydrocolloid dressings provide a moist environment that
promotes autolytic debridement, which helps remove necrotic tissue and slough. This dressing is
appropriate for wounds with moderate to heavy drainage.
Option A is incorrect because dry gauze dressings do not provide a moist healing environment. Option B
is incorrect because nonadherent dressings are used for clean wounds. Option D is incorrect because
transparent film dressings are used for clean, dry wounds.
,A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How
would the nurse document this wound?
a. Red wound
b. Yellow wound
c. Full-thickness wound
d. Stage III pressure ulcer
✔️ Correct Answer: A
Rationale:
The nurse should document this wound as a red wound (Option A). Red wounds contain healthy
granulation tissue, which is deep pink to bright red in color. Granulation tissue indicates the wound is
healing properly. The wound appears red and is actively forming new tissue. Red wounds require
protection and a moist environment to promote healing.
Option B is incorrect because yellow wounds contain slough (yellow or yellow-green tissue) and require
debridement. Option C is incorrect because full-thickness describes the depth of the wound, not the
color. Option D is incorrect because Stage III pressure ulcer refers to a specific depth category, not the
appearance of granulation tissue.
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action
is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell count
b. Check the skin for areas of redness
c. Check the temperature every 2 hours
d. Ask about fatigue or feelings of malaise
✔️ Correct Answer: D
Rationale:
The nurse should ask about fatigue or feelings of malaise (Option D). Corticosteroids suppress the
immune system and mask typical signs of infection such as fever and inflammation. Early signs of
infection in patients on corticosteroids may include vague symptoms such as fatigue, malaise, and subtle
changes in condition. The nurse should assess for these non-specific symptoms to detect infection early.
Option A is incorrect because corticosteroids can mask leukocytosis; WBC count may not be elevated.
Option B is incorrect because corticosteroids may mask inflammation and redness. Option C is incorrect
while temperature monitoring is important, corticosteroids can mask fever.
, The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas
✔️ Correct Answer: D
Rationale:
A wet-to-dry dressing should be used for a patient with a wound that has purulent drainage and dry
brown areas (Option D). Wet-to-dry dressings are used for mechanical debridement of wounds with
necrotic tissue, slough, or purulent drainage. The wet gauze is placed in the wound, allowed to dry, and
then removed, which debrides the wound of dead tissue and debris.
Option A is incorrect because wet-to-dry dressings are not used on wounds with healthy granulation
tissue. Option B is incorrect because approximated surgical incisions require clean, dry dressings. Option
C is incorrect because full-thickness burns require specialized burn dressings.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base
of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure
ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
✔️ Correct Answer: C
Rationale:
This pressure ulcer should be classified as Stage III (Option C). A Stage III pressure ulcer involves full-
thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer extends into, but not
through, the underlying fascia. The wound base may be yellow (slough) and may have undermining or
tunneling. Subcutaneous tissue involvement is characteristic of Stage III ulcers.
Option A is incorrect because Stage I ulcers are non-blanchable erythema on intact skin. Option B is
incorrect because Stage II ulcers are partial-thickness with damage to epidermis and dermis. Option D is
incorrect because Stage IV ulcers involve damage to muscle, bone, or supporting structures.
