ATI RN MEDICAL SURGICAL PRACTICE
EXAM 2024-2025 FORM A AND B EXAM
QUESTIONS WITH CORRECT VERIFIED
ANSWERS WITH RATIONALES
A nurse is caring for a client who is postoperative following a total hip arthroplasty.
Which of the following findings indicates that the client is experiencing a
complication?
- The client reports that the sequential compression devices (SCDs) are uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to drainage
- The client needs assistance with a walker when ambulating in the room --
CORRECT ANSWER: - The client's surgical site dressing has required changing
twice in 2 hr due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor clotting
and increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs --CORRECT ANSWER: - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to
assess the client's vital signs. A client who has portal HTN can develop esophageal
varices, which are fragile and can rupture, resulting in large amounts of blood loss and
shock. Obtaining vital signs provides information about the client's condition that can
contribute to decision making.
A nurse is providing teaching to a female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an
understanding of the teaching?
- "Taking my daily progesterone should improve my symptoms."
- "A risk factor for my condition is obesity."
- "I should limit my daily fluid intake."
- "I will switch my morning cup of coffee to hot tea." --CORRECT ANSWER: - "A
risk factor for my condition is obesity."
RATIONALE: Excess weight creates increased abdominal pressure that can result in
stress incontinence.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
,- "Ginkgo biloba relieves nausea for people who have vertigo."
- "Taking ginkgo biloba will help relieve your joint pain."
- "Ginkgo biloba can cause an increased risk for bleeding."
- "Taking ginkgo biloba decreases the risk of migraine headaches." --CORRECT
ANSWER: - "Ginkgo biloba can cause an increased risk for bleeding."
RATIONALE: Ginkgo biloba increases blood flow and is effective in decreasing the
pain associated with peripheral artery disease. The supplement also decreases platelet
aggregation, which in turn, increases the risk for bleeding. Clients who have been
prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba
without first speaking with their provider.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving?
- Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
- pH 7.28 (7.35 to 7.45)
- Glucose 272 mg/dL (74 to 106 mg/dL)
- HCO3- 14 mEq/L (21 to 28 mEq/L) --CORRECT ANSWER: - Glucose 272 mg/dL
(74 to 106 mg/dL)
RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is providing discharge teaching to a client who is postoperative following a
modified radical mastectomy. Which of the following instructions should the nurse
include?
- Flex the affected arm when ambulating
- Numbness can occur along the inside of the affected arm
- Begin ROM exercises 1 day after surgery
- Dress in clothing that fits snugly --CORRECT ANSWER: - Numbness can occur
along the inside of the affected arm
RATIONALE: The nurse should instruct the client that numbness can occur near the
incision and along the inside of the affected arm due to nerve injury.
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. Which of the following findings should the nurse report to the
provider as an adverse effect of this medication?
- Decreased heart rate
- Crackles heard on auscultation
- Increased urinary output
- Decreased deep tendon reflexes --CORRECT ANSWER: - Crackles heard on
auscultation
RATIONALE: Mannitol is an osmotic diuretic that prevents the reabsorption of water
in the kidneys, thus increasing urinary output. With the exception of the brain,
mannitol can leave the vascular system at the capillary site, which can result in edema.
The nurse should identify crackles as a manifestation of pulmonary edema and notify
the provider. Other manifestations include dyspnea and decreased oxygen saturation.
, A nurse at an urgent care clinic is caring for a client who is experiencing an
anaphylactic reaction. After ensuring a patent airway, which of the following
interventions is the priority?
- Obtaining vital signs
- Placing the client in Fowler's position
- Administering epinephrine
- Initiating an IV infusion of 0.9% sodium chloride --CORRECT ANSWER: -
Administering epinephrine
RATIONALE: Evidence-based practice indicates that the priority intervention is for
the nurse to administer epinephrine quickly to dilate the bronchioles and prevent
circulatory shock.
A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
- Loosen the clothing around the client's neck
- Check the client's pupillary response
- Turn the client to the side
- Move furniture away from the client --CORRECT ANSWER: - Turn the client to
the side
RATIONALE: The greatest risk to this client is hypoxia from an impaired airway.
Therefore, the priority intervention the nurse should take is to place the client in a
side-lying position to prevent aspiration.
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
- Flush the line before administering antibiotics
- Position the client in Trendelenburg to obtain measurements
- Have the client bear down when readings are obtained
- Place a pressure bag around the flush solution --CORRECT ANSWER: - Place a
pressure bag around the flush solution
RATIONALE: The nurse should place a pressure bag around the flush solution of
0.9% sodium chloride because the pressure from an artery is greater than that of the
line.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is
NPO. When reviewing the chart, the nurse notes the following prescription: capillary
blood glucose AC and HS. Which of the following actions should the nurse take?
- Check the client's blood glucose according to facility mealtimes
- Contact the provider to clarify the prescription
- Request for meals to be provided for the client
- Hold the prescription until client is no longer NPO --CORRECT ANSWER: -
Contact the provider to clarify the prescription
RATIONALE: Mealtimes do not pertain to this client due to the NPO status. The
nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or
per facility protocol. Thus, the prescription requires clarification.
EXAM 2024-2025 FORM A AND B EXAM
QUESTIONS WITH CORRECT VERIFIED
ANSWERS WITH RATIONALES
A nurse is caring for a client who is postoperative following a total hip arthroplasty.
Which of the following findings indicates that the client is experiencing a
complication?
- The client reports that the sequential compression devices (SCDs) are uncomfortable
- The client reports pain at the surgical site as 4 on a scale of 0 to 10.
- The client's surgical site dressing has required changing twice in 2 hr due to drainage
- The client needs assistance with a walker when ambulating in the room --
CORRECT ANSWER: - The client's surgical site dressing has required changing
twice in 2 hr due to drainage
RATIONALE: Frequent dressing changing after surgery may indicate poor clotting
and increased bleeding.
A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs --CORRECT ANSWER: - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to
assess the client's vital signs. A client who has portal HTN can develop esophageal
varices, which are fragile and can rupture, resulting in large amounts of blood loss and
shock. Obtaining vital signs provides information about the client's condition that can
contribute to decision making.
A nurse is providing teaching to a female client who has stress incontinence and a
BMI of 32. Which of the following statements by the client indicates an
understanding of the teaching?
- "Taking my daily progesterone should improve my symptoms."
- "A risk factor for my condition is obesity."
- "I should limit my daily fluid intake."
- "I will switch my morning cup of coffee to hot tea." --CORRECT ANSWER: - "A
risk factor for my condition is obesity."
RATIONALE: Excess weight creates increased abdominal pressure that can result in
stress incontinence.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal
supplement. Which of the following statements should the nurse make?
,- "Ginkgo biloba relieves nausea for people who have vertigo."
- "Taking ginkgo biloba will help relieve your joint pain."
- "Ginkgo biloba can cause an increased risk for bleeding."
- "Taking ginkgo biloba decreases the risk of migraine headaches." --CORRECT
ANSWER: - "Ginkgo biloba can cause an increased risk for bleeding."
RATIONALE: Ginkgo biloba increases blood flow and is effective in decreasing the
pain associated with peripheral artery disease. The supplement also decreases platelet
aggregation, which in turn, increases the risk for bleeding. Clients who have been
prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba
without first speaking with their provider.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving?
- Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
- pH 7.28 (7.35 to 7.45)
- Glucose 272 mg/dL (74 to 106 mg/dL)
- HCO3- 14 mEq/L (21 to 28 mEq/L) --CORRECT ANSWER: - Glucose 272 mg/dL
(74 to 106 mg/dL)
RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is providing discharge teaching to a client who is postoperative following a
modified radical mastectomy. Which of the following instructions should the nurse
include?
- Flex the affected arm when ambulating
- Numbness can occur along the inside of the affected arm
- Begin ROM exercises 1 day after surgery
- Dress in clothing that fits snugly --CORRECT ANSWER: - Numbness can occur
along the inside of the affected arm
RATIONALE: The nurse should instruct the client that numbness can occur near the
incision and along the inside of the affected arm due to nerve injury.
A nurse is caring for a client who has increased ICP and is receiving mannitol via
continuous IV infusion. Which of the following findings should the nurse report to the
provider as an adverse effect of this medication?
- Decreased heart rate
- Crackles heard on auscultation
- Increased urinary output
- Decreased deep tendon reflexes --CORRECT ANSWER: - Crackles heard on
auscultation
RATIONALE: Mannitol is an osmotic diuretic that prevents the reabsorption of water
in the kidneys, thus increasing urinary output. With the exception of the brain,
mannitol can leave the vascular system at the capillary site, which can result in edema.
The nurse should identify crackles as a manifestation of pulmonary edema and notify
the provider. Other manifestations include dyspnea and decreased oxygen saturation.
, A nurse at an urgent care clinic is caring for a client who is experiencing an
anaphylactic reaction. After ensuring a patent airway, which of the following
interventions is the priority?
- Obtaining vital signs
- Placing the client in Fowler's position
- Administering epinephrine
- Initiating an IV infusion of 0.9% sodium chloride --CORRECT ANSWER: -
Administering epinephrine
RATIONALE: Evidence-based practice indicates that the priority intervention is for
the nurse to administer epinephrine quickly to dilate the bronchioles and prevent
circulatory shock.
A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
- Loosen the clothing around the client's neck
- Check the client's pupillary response
- Turn the client to the side
- Move furniture away from the client --CORRECT ANSWER: - Turn the client to
the side
RATIONALE: The greatest risk to this client is hypoxia from an impaired airway.
Therefore, the priority intervention the nurse should take is to place the client in a
side-lying position to prevent aspiration.
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take?
- Flush the line before administering antibiotics
- Position the client in Trendelenburg to obtain measurements
- Have the client bear down when readings are obtained
- Place a pressure bag around the flush solution --CORRECT ANSWER: - Place a
pressure bag around the flush solution
RATIONALE: The nurse should place a pressure bag around the flush solution of
0.9% sodium chloride because the pressure from an artery is greater than that of the
line.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is
NPO. When reviewing the chart, the nurse notes the following prescription: capillary
blood glucose AC and HS. Which of the following actions should the nurse take?
- Check the client's blood glucose according to facility mealtimes
- Contact the provider to clarify the prescription
- Request for meals to be provided for the client
- Hold the prescription until client is no longer NPO --CORRECT ANSWER: -
Contact the provider to clarify the prescription
RATIONALE: Mealtimes do not pertain to this client due to the NPO status. The
nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or
per facility protocol. Thus, the prescription requires clarification.
