ATI MEDSURG 2 PROCTORED 2016 EXAM LATEST UPDATED 2025 ANSWERS WITH RATIONALE
→PRIORITY TWO
A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment.
Which of thefollowing instructions should the nurse include?
Pat the skin on the radiation site to dry it
Apply OTC moisturizer to the radiation site
Cover the radiation site loosely with a gauze wrap before dressing
Use a soft washcloth to clean the area around the radiation siteRationale: pg. 584. Dry the area
thoroughly using patting motions.
A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client
has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should
anticipate administering which of thefollowing prescribed medications?
Diphenhydramine
Acetaminophen
Pantoprazole
Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to
preventcardiovascular/respiratory distress.
A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
Lungs clear
Apical pulse 82/min
Hyperactive bowel sounds
Blood pressure 90/50 mm Hg
Rationale: pg. 278 Confirmed on answer sheet
A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse
should recognizethese findings as indication of which of the following conditions?
Metabolic acidosis
Metabolic alkalosis
,Compensated respiratory alkalosis
Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis.
A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of
the following labsshould the nurse expect during the first 24 hours
Decreased BUN (elevated due to fluid loss)
Hypoglycemia (High due to stress)
Hypoalbuminemia (Low due to fluid loss)
Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)Rationale: Pg. 481 ATI.
Total protein and albumin- low due to fluid loss.
A nurse is assessing a client who is 12hr postoperative following a colon resection.
Which of the following findings shouldthe nurse report to the surgeon?
Heart rate 90/min
Absent bowel sounds
Hgb 8.2 g/dl
Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.
A nurse is caring for a client who has diabetes insipidus. Which of the following medications should
the nurse plan toadminister?
Desmopressin
Regular insulin
Furosemide
Lithium carbonate
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase
ADH and to stop patienton urinating.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily
for 3 years.Which of the following test should the nurse monitor?
Fasting blood glucose
Stool for occult blood - GI bleed
Urine for white blood cells
Serum calcium
,Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed
(bloo
dy,tarry stools, abdominal pain).
A nurse in the emergency department is assessing a client. Which of the following actions should the
nurse take first (Click on the “Exhibit” button for additional information about the client. There are
three tabs that contain separate categories ofdata.)
Obtain a sputum sample for culture
Prepare the client for a chest x-ray
Initiate airborne precautions
Administer ondansetron.
, Rationale: No idea what the Exhibit is all about; won’t be able to answer it.
A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain.
Which ofthe following prescriptions should the nurse anticipate?
Transmucosal fentanyl
Intramuscular meperidine
Oral acetaminophen
Intravenous dexamethasone
Rationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to
severe pain. Ashort-acting pain medication is administered for breakthrough pain.
A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor.
Which of thefollowing should the nurse analyze to determine whether the client is experiencing a
myocardial infarction?
PR interval
QRS duration
T wave
ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
→PRIORITY TWO
A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment.
Which of thefollowing instructions should the nurse include?
Pat the skin on the radiation site to dry it
Apply OTC moisturizer to the radiation site
Cover the radiation site loosely with a gauze wrap before dressing
Use a soft washcloth to clean the area around the radiation siteRationale: pg. 584. Dry the area
thoroughly using patting motions.
A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client
has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should
anticipate administering which of thefollowing prescribed medications?
Diphenhydramine
Acetaminophen
Pantoprazole
Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to
preventcardiovascular/respiratory distress.
A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
Lungs clear
Apical pulse 82/min
Hyperactive bowel sounds
Blood pressure 90/50 mm Hg
Rationale: pg. 278 Confirmed on answer sheet
A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse
should recognizethese findings as indication of which of the following conditions?
Metabolic acidosis
Metabolic alkalosis
,Compensated respiratory alkalosis
Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis.
A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of
the following labsshould the nurse expect during the first 24 hours
Decreased BUN (elevated due to fluid loss)
Hypoglycemia (High due to stress)
Hypoalbuminemia (Low due to fluid loss)
Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)Rationale: Pg. 481 ATI.
Total protein and albumin- low due to fluid loss.
A nurse is assessing a client who is 12hr postoperative following a colon resection.
Which of the following findings shouldthe nurse report to the surgeon?
Heart rate 90/min
Absent bowel sounds
Hgb 8.2 g/dl
Gastric pH of 3.0
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.
A nurse is caring for a client who has diabetes insipidus. Which of the following medications should
the nurse plan toadminister?
Desmopressin
Regular insulin
Furosemide
Lithium carbonate
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin increase
ADH and to stop patienton urinating.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily
for 3 years.Which of the following test should the nurse monitor?
Fasting blood glucose
Stool for occult blood - GI bleed
Urine for white blood cells
Serum calcium
,Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed
(bloo
dy,tarry stools, abdominal pain).
A nurse in the emergency department is assessing a client. Which of the following actions should the
nurse take first (Click on the “Exhibit” button for additional information about the client. There are
three tabs that contain separate categories ofdata.)
Obtain a sputum sample for culture
Prepare the client for a chest x-ray
Initiate airborne precautions
Administer ondansetron.
, Rationale: No idea what the Exhibit is all about; won’t be able to answer it.
A nurse is contacting the provider for a client who has cancer and is experiencing breakthrough pain.
Which ofthe following prescriptions should the nurse anticipate?
Transmucosal fentanyl
Intramuscular meperidine
Oral acetaminophen
Intravenous dexamethasone
Rationale: ATI pg. 27 Morphine sulfate and fentanyl are opioid agents used to treat moderate to
severe pain. Ashort-acting pain medication is administered for breakthrough pain.
A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor.
Which of thefollowing should the nurse analyze to determine whether the client is experiencing a
myocardial infarction?
PR interval
QRS duration
T wave
ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
