ATI NCLEX Medical
Surgical Assessment
2024/2025
1. A nurse is teaching a client how to administer a medication using an inhaler with a
spacer. Which of the following instructions should the nurse include?
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use"
2. A nurse is planning care for a client who is receiving mechanical ventilation.
Which of the following actions should the nurse include in the plan?
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr
3. A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness of
the treatment?
, A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
4. A nurse is monitoring the laboratory findings for a client who is postoperative
following a total hip arthroplasty 6 hr ago. Which of the following values indicates
that the client has an increased risk for bleeding?
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million
5. A nurse is admitting a client who has a cervical spinal cord injury following a
motor vehicle crash. Which of the following interventions is the nurse's priority
while caring for this client?
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing
6. A nurse is caring for a client who is receiving a blood transfusion. Which of the
following findings indicates that the client is experiencing transfusion-associated
, circulatory overload?
A. Nausea
B. Hypothermia
C. Dyspnea
D. Bradycardia
7. A nurse is assessing a client who has lung cancer and is undergoing radiation
therapy to the chest. Which of the following indicates an adverse effect of the
therapy?
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold
8. A nurse is preparing to administer a unit of packed RBCs to a client who has
anemia. Which of the following actions should the nurse plan to take (select all that
apply)?
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access
, 9. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which
of the following BUN levels should the nurse expect?
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
10.A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation (read description)?
A. Multiple irregular and variable waves at the baseline and irregular R to R
intervals
B. A rate of 140-180/min
C. A tachycardia with no identifiable P wave and is determined to originate
somewhere other than the ventricles. Rate between 100-280/min
D. A P wave for every QRS, rate is 60-100/min
11.A nurse is preparing to admit a client who has a new tracheostomy from the
operating room. Which of the following items is the priority for the nurse to have
available in the client's room upon admission?
A. Obturator
B. Hydrogen peroxide
Surgical Assessment
2024/2025
1. A nurse is teaching a client how to administer a medication using an inhaler with a
spacer. Which of the following instructions should the nurse include?
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use"
2. A nurse is planning care for a client who is receiving mechanical ventilation.
Which of the following actions should the nurse include in the plan?
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr
3. A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness of
the treatment?
, A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
4. A nurse is monitoring the laboratory findings for a client who is postoperative
following a total hip arthroplasty 6 hr ago. Which of the following values indicates
that the client has an increased risk for bleeding?
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million
5. A nurse is admitting a client who has a cervical spinal cord injury following a
motor vehicle crash. Which of the following interventions is the nurse's priority
while caring for this client?
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing
6. A nurse is caring for a client who is receiving a blood transfusion. Which of the
following findings indicates that the client is experiencing transfusion-associated
, circulatory overload?
A. Nausea
B. Hypothermia
C. Dyspnea
D. Bradycardia
7. A nurse is assessing a client who has lung cancer and is undergoing radiation
therapy to the chest. Which of the following indicates an adverse effect of the
therapy?
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold
8. A nurse is preparing to administer a unit of packed RBCs to a client who has
anemia. Which of the following actions should the nurse plan to take (select all that
apply)?
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access
, 9. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which
of the following BUN levels should the nurse expect?
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
10.A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation (read description)?
A. Multiple irregular and variable waves at the baseline and irregular R to R
intervals
B. A rate of 140-180/min
C. A tachycardia with no identifiable P wave and is determined to originate
somewhere other than the ventricles. Rate between 100-280/min
D. A P wave for every QRS, rate is 60-100/min
11.A nurse is preparing to admit a client who has a new tracheostomy from the
operating room. Which of the following items is the priority for the nurse to have
available in the client's room upon admission?
A. Obturator
B. Hydrogen peroxide
