ATI RN MED SURG Exam Questions and
ANSWERS
1.01A01nurse01in01a01burn01treatment01center01is01caring01for01a01client01who01is
01admitted01with01severe01burns01to01both01lower01extremities01and01is01pending01
an01escharotomy.01The01client’s01spouse0 1 asks0 1 the01nurse01what0 1 the0 1 procedu
re0 1 entails.0 1 Which0 1 of01the0 1 following01nursing01statements01is01appropriate?
a. “large01incisions01will01be01made01in01the01eschar01to01improve01circulation
”
b. “01I01can01call01the01doctor01back01here01if01you01want01me01to”
c. “a01piece01of01skin01will01be01removed01and01grafted01over01the01burned01area”
d. “dead01tissue01will01be01surgically01removed”
2. A01nurse01is01monitoring01the01fluid01replacement01of01a01client01who01has01sus
tained01burns.01Which01of01the01following01fluids01is01used01in01the01first012401h
ours01following01a01burn01injury?
a. 5%01dextrose01in01water
b. 5%01dextrose01in01normal01saline
c. normal01saline
d. lactated01ringers
3. A01nurse01is01caring01for01a01client01who01has01full-
thickness01burns01all01over0175%01of01his01body.01Which01of01the01following01m
ethods01is01appropriate01to01accurately01monitor01the01cardiovascular01system?
a. auscultate01cuff01blood01pressure
b. palpate01pulse01pressure
c. obtain01a01central01venous01pressure
d. monitor01the01pulmonary01artery01pressure
4. A01nurse01is01assessing01the01depth01and01extent01of01a01client01who01has01seve
re01burns01to01the01face,01neck,01and01upper01extremities.01Which01of01the01followi
ng01factors01is01the01first01priority01when01assessing01the01severity01of01the01burn
?
a. Age01of01the01client
b. Associated01medical01history
c. Location01of01the01burn
d. Cause01of01the01burn
5. A01client01arrives01at01the01emergency01dept01following01an01explosion01at01t
he01chemical01plant.01He01has01deep01partial01and01full-
thickness01chemical01burns01over01more01than012501%01of01his01body01surface01a
rea.01What01is01the01nurse’s01priority01intervention?
a. Initiate01fluid01resuscitation
b. Medication01for01pain
c. Administer01antibiotics
,d. Maintain01a01patent01airway
6. A01nurse01is01caring01for01a01client01who01came01the01emergency01dept01reportin
g01chest01pain.01The01provider01suspects01a01myocardial01infarction.01While01waitin
g01for01the01laboratory01to01report01the01client’s01troponin01levels,01the01client01ask
s01what01this01blood01test01will01show.
The01nurse01should01explain01that01troponin01is
a. An01enzyme01that01indicates01damage01to01brain,01heart,01and01skelet
al01muscle01tissues
b. A01protein01whose01levels01reflect01the01risk01for01coronary01artery01disease
c. A01heart01muscle01protein01that01appears01in01the01bloodstream01wh
en01there01is01damage01to01the01heart
d. A01protein01that01helps01transport01oxygen01throughout01the01body
7. A01nurse01is01assessing01a01client01who01has01disseminated01intravascular01c
oagulation01(DIC).01Which01of01the01following01should01the01nurse01expect01i
n01the01findings?
a. Excessive01thrombosis01and01bleeding
b. Progressive01increase01in01platelet01production
c. Immediate01sodium01and01fluid01retention
d. Increased01clotting01factors
8. A01nurse01is01about01to01administer01warfarin01(Coumadin)01to01a01client01w
ho01has01atrial01fibrillation.01When01the01client01asks01what01his01medication0
1will01do,01which01of01the01following01is01an01appropriate01nursing01response?
a. It01helps01convert01atrial01fibrillation01to01sinus01rhythm
b. Is01dissolves01clots01in01the01bloodstream
c. It01slows01the01response01of01the01ventricles01to01the01fast01atrial01impulses
d. It01prevents01strokes01in01clients01who01have01atrial01fibrillation
9. A01nurse01in01a01cardiac01care01unit01is01caring01for01a01client01with01acute01hear
t01failure.01Which01of01the01following01findings01should01the01nurse01expect?
a. Decreased01brain01natriuretic01peptide01(BNP)
b. Elevated01central01venous01pressure01(CVP)
c. Decreased01pulmonary01pressure
d. Increases01urinary01output
10. A01client01comes01into01the01ED01reporting01nausea01and01vomiting01that01w
orsens01when01lying01down01and01without01relief01from01antacids.01The01provide
r01suspects01acute01pancreatitis.01Which01of01the01following01lab01test01results01sh
ould01the01nurse01expect01to01see01if01the01client01has01acute01pancreatitis?
a. Decreased01WBC
, b. Increased01serum01amylase
c. Decreased01serum01lipase
d. Increased01serum01calcium
11. A01nurse01in01the01ICU01is01caring01for01a01client01who01has01acute01respir
atory01distress01syndrome01(ARDS)01and01is01receiving01mechanical01via01an01
endotracheal01tube.01The01provider01plans01to01extubate01her01within01the01nex
t012401hour.01Which01of01the01following01is01an01important01criterion01for01extu
bating01the01client?
a. Ability01to01cough01effectively
b. Adequate01tidal01volume01without01manually01assisted01breaths
c. No01indication01of01infection
d. No01need01for01supplemental01oxygen
12. A01nurse01is01caring01for01a01client01following01a01CT01scan01with01dye01who01
suffered01from01an01anaphylactic01reaction.01Which01of01the01following01conditions
01requires01a01priority01nursing01response?
a. urticaria
b. stridor
c. tachypnea
d. angioedema
13. A01nurse01is01caring01for01a01female01client01who01came01in01to01the01ED01rep
orting01SOB01and01pain01in01the01lung01area.01Her01heart01rate01is01110/min,01res
p.01rate0140/min,01and01blood01pressure01140/8001m8juiimHg.01Her01arterial01blo
od01gases01are:01pH017.5,01PaCO2012901mmHg,01PaO2016001mm01Hg,01HCO3012001m
Eq/L,01and01SaO20186%.01Which01of01the01following01is01the01priority01interventio
n?
a. Prepare01for01mechanical01ventilation
b. Administer01oxygen01via01face01mask
c. Prepare01to01administer01a01sedative
d. Monitor01for01pulmonary01embolism
14. A01nurse01is01monitoring01a01client01who01has01just01had01a01thoracentesis01to01r
emove01pleural01fluid.01Which01of01the01following01clinical01manifestations01indica
te01a01complication01that01requires01notifying01the01provider01immediately?
a. Serosanguineous01drainage01from01the01puncture01site
b. Discomfort01at01the01puncture01site
c. Increased01heart01rate
d. Decreased01temperature
15. A01group01of01college01students01was01attending01a01weekend01football01rally01
when01one01of01the01students01stumbled01and01fell01into01the01bonfire.01Although
01several01friends01quickly
ANSWERS
1.01A01nurse01in01a01burn01treatment01center01is01caring01for01a01client01who01is
01admitted01with01severe01burns01to01both01lower01extremities01and01is01pending01
an01escharotomy.01The01client’s01spouse0 1 asks0 1 the01nurse01what0 1 the0 1 procedu
re0 1 entails.0 1 Which0 1 of01the0 1 following01nursing01statements01is01appropriate?
a. “large01incisions01will01be01made01in01the01eschar01to01improve01circulation
”
b. “01I01can01call01the01doctor01back01here01if01you01want01me01to”
c. “a01piece01of01skin01will01be01removed01and01grafted01over01the01burned01area”
d. “dead01tissue01will01be01surgically01removed”
2. A01nurse01is01monitoring01the01fluid01replacement01of01a01client01who01has01sus
tained01burns.01Which01of01the01following01fluids01is01used01in01the01first012401h
ours01following01a01burn01injury?
a. 5%01dextrose01in01water
b. 5%01dextrose01in01normal01saline
c. normal01saline
d. lactated01ringers
3. A01nurse01is01caring01for01a01client01who01has01full-
thickness01burns01all01over0175%01of01his01body.01Which01of01the01following01m
ethods01is01appropriate01to01accurately01monitor01the01cardiovascular01system?
a. auscultate01cuff01blood01pressure
b. palpate01pulse01pressure
c. obtain01a01central01venous01pressure
d. monitor01the01pulmonary01artery01pressure
4. A01nurse01is01assessing01the01depth01and01extent01of01a01client01who01has01seve
re01burns01to01the01face,01neck,01and01upper01extremities.01Which01of01the01followi
ng01factors01is01the01first01priority01when01assessing01the01severity01of01the01burn
?
a. Age01of01the01client
b. Associated01medical01history
c. Location01of01the01burn
d. Cause01of01the01burn
5. A01client01arrives01at01the01emergency01dept01following01an01explosion01at01t
he01chemical01plant.01He01has01deep01partial01and01full-
thickness01chemical01burns01over01more01than012501%01of01his01body01surface01a
rea.01What01is01the01nurse’s01priority01intervention?
a. Initiate01fluid01resuscitation
b. Medication01for01pain
c. Administer01antibiotics
,d. Maintain01a01patent01airway
6. A01nurse01is01caring01for01a01client01who01came01the01emergency01dept01reportin
g01chest01pain.01The01provider01suspects01a01myocardial01infarction.01While01waitin
g01for01the01laboratory01to01report01the01client’s01troponin01levels,01the01client01ask
s01what01this01blood01test01will01show.
The01nurse01should01explain01that01troponin01is
a. An01enzyme01that01indicates01damage01to01brain,01heart,01and01skelet
al01muscle01tissues
b. A01protein01whose01levels01reflect01the01risk01for01coronary01artery01disease
c. A01heart01muscle01protein01that01appears01in01the01bloodstream01wh
en01there01is01damage01to01the01heart
d. A01protein01that01helps01transport01oxygen01throughout01the01body
7. A01nurse01is01assessing01a01client01who01has01disseminated01intravascular01c
oagulation01(DIC).01Which01of01the01following01should01the01nurse01expect01i
n01the01findings?
a. Excessive01thrombosis01and01bleeding
b. Progressive01increase01in01platelet01production
c. Immediate01sodium01and01fluid01retention
d. Increased01clotting01factors
8. A01nurse01is01about01to01administer01warfarin01(Coumadin)01to01a01client01w
ho01has01atrial01fibrillation.01When01the01client01asks01what01his01medication0
1will01do,01which01of01the01following01is01an01appropriate01nursing01response?
a. It01helps01convert01atrial01fibrillation01to01sinus01rhythm
b. Is01dissolves01clots01in01the01bloodstream
c. It01slows01the01response01of01the01ventricles01to01the01fast01atrial01impulses
d. It01prevents01strokes01in01clients01who01have01atrial01fibrillation
9. A01nurse01in01a01cardiac01care01unit01is01caring01for01a01client01with01acute01hear
t01failure.01Which01of01the01following01findings01should01the01nurse01expect?
a. Decreased01brain01natriuretic01peptide01(BNP)
b. Elevated01central01venous01pressure01(CVP)
c. Decreased01pulmonary01pressure
d. Increases01urinary01output
10. A01client01comes01into01the01ED01reporting01nausea01and01vomiting01that01w
orsens01when01lying01down01and01without01relief01from01antacids.01The01provide
r01suspects01acute01pancreatitis.01Which01of01the01following01lab01test01results01sh
ould01the01nurse01expect01to01see01if01the01client01has01acute01pancreatitis?
a. Decreased01WBC
, b. Increased01serum01amylase
c. Decreased01serum01lipase
d. Increased01serum01calcium
11. A01nurse01in01the01ICU01is01caring01for01a01client01who01has01acute01respir
atory01distress01syndrome01(ARDS)01and01is01receiving01mechanical01via01an01
endotracheal01tube.01The01provider01plans01to01extubate01her01within01the01nex
t012401hour.01Which01of01the01following01is01an01important01criterion01for01extu
bating01the01client?
a. Ability01to01cough01effectively
b. Adequate01tidal01volume01without01manually01assisted01breaths
c. No01indication01of01infection
d. No01need01for01supplemental01oxygen
12. A01nurse01is01caring01for01a01client01following01a01CT01scan01with01dye01who01
suffered01from01an01anaphylactic01reaction.01Which01of01the01following01conditions
01requires01a01priority01nursing01response?
a. urticaria
b. stridor
c. tachypnea
d. angioedema
13. A01nurse01is01caring01for01a01female01client01who01came01in01to01the01ED01rep
orting01SOB01and01pain01in01the01lung01area.01Her01heart01rate01is01110/min,01res
p.01rate0140/min,01and01blood01pressure01140/8001m8juiimHg.01Her01arterial01blo
od01gases01are:01pH017.5,01PaCO2012901mmHg,01PaO2016001mm01Hg,01HCO3012001m
Eq/L,01and01SaO20186%.01Which01of01the01following01is01the01priority01interventio
n?
a. Prepare01for01mechanical01ventilation
b. Administer01oxygen01via01face01mask
c. Prepare01to01administer01a01sedative
d. Monitor01for01pulmonary01embolism
14. A01nurse01is01monitoring01a01client01who01has01just01had01a01thoracentesis01to01r
emove01pleural01fluid.01Which01of01the01following01clinical01manifestations01indica
te01a01complication01that01requires01notifying01the01provider01immediately?
a. Serosanguineous01drainage01from01the01puncture01site
b. Discomfort01at01the01puncture01site
c. Increased01heart01rate
d. Decreased01temperature
15. A01group01of01college01students01was01attending01a01weekend01football01rally01
when01one01of01the01students01stumbled01and01fell01into01the01bonfire.01Although
01several01friends01quickly
