ATI RN ADULT MEDICAL SURGICAL
EXAM questions with correct answers
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
➰CORRECT ANSWERS ✔✔Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to
reduce the risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest
drainage system. Which of the following findings is an indication of lung re-
expansion? - ➰CORRECT ANSWERS ✔✔Bubbling in the water seal chamber
has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-
expands.
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the following values should the nurse
identify as a desired outcome for this therapy? - ➰CORRECT ANSWERS
✔✔INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke,
myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since
warfarin is an anticoagulant, the medication must be monitored to ensure the
anticoagulation is within the therapeutic range and prevent hemorrhage (high
levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation).
,An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who
has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1
pressure injury on the greater trochanter of his left hip. Which of the following
instructions should the nurse include in the teaching? - ➰CORRECT
ANSWERS ✔✔Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the
hips when in a lateral position to no more than 30°. This positioning prevents
direct pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which
of the following findings is the nurse's priority to report to the provider? -
➰CORRECT ANSWERS ✔✔Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding to report to the provider is
restlessness, which can be an indication the client is experiencing
disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid
removal of electrolytes from the client's blood and can lead to dysrhythmias or
seizures. Other manifestations include nausea, vomiting, fatigue, and
headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ➰CORRECT ANSWERS ✔✔Scan the
bladder with a portable ultrasound.
, Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders
presents the greatest risk to this group of clients? - ➰CORRECT ANSWERS
✔✔Hypertension
Rationale: When using the safety/risk reduction approach to client care, the
nurse should determine that the disorder with the greatest risk for this group
of clients is hypertension. The prevalence of hypertension is highest among
African American clients, followed by Caucasian clients, and then Hispanic
clients.
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? -
➰CORRECT ANSWERS ✔✔Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in
the client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10
min. ago. Which of the following findings should the nurse report to the
provider immediately? - ➰CORRECT ANSWERS ✔✔Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is stridor. Stridor can indicate a
narrowing airway or possible obstruction caused by edema or laryngeal
spasms. The nurse should report the finding immediately and implement an
intervention.
EXAM questions with correct answers
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? -
➰CORRECT ANSWERS ✔✔Flex the foot every hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to
reduce the risk for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest
drainage system. Which of the following findings is an indication of lung re-
expansion? - ➰CORRECT ANSWERS ✔✔Bubbling in the water seal chamber
has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-
expands.
A nurse is reviewing the medical record of a client who is taking warfarin for
chronic atrial fibrillation. Which of the following values should the nurse
identify as a desired outcome for this therapy? - ➰CORRECT ANSWERS
✔✔INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke,
myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since
warfarin is an anticoagulant, the medication must be monitored to ensure the
anticoagulation is within the therapeutic range and prevent hemorrhage (high
levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation).
,An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who
has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1
pressure injury on the greater trochanter of his left hip. Which of the following
instructions should the nurse include in the teaching? - ➰CORRECT
ANSWERS ✔✔Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the
hips when in a lateral position to no more than 30°. This positioning prevents
direct pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which
of the following findings is the nurse's priority to report to the provider? -
➰CORRECT ANSWERS ✔✔Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding to report to the provider is
restlessness, which can be an indication the client is experiencing
disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid
removal of electrolytes from the client's blood and can lead to dysrhythmias or
seizures. Other manifestations include nausea, vomiting, fatigue, and
headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ➰CORRECT ANSWERS ✔✔Scan the
bladder with a portable ultrasound.
, Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders
presents the greatest risk to this group of clients? - ➰CORRECT ANSWERS
✔✔Hypertension
Rationale: When using the safety/risk reduction approach to client care, the
nurse should determine that the disorder with the greatest risk for this group
of clients is hypertension. The prevalence of hypertension is highest among
African American clients, followed by Caucasian clients, and then Hispanic
clients.
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? -
➰CORRECT ANSWERS ✔✔Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in
the client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10
min. ago. Which of the following findings should the nurse report to the
provider immediately? - ➰CORRECT ANSWERS ✔✔Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is stridor. Stridor can indicate a
narrowing airway or possible obstruction caused by edema or laryngeal
spasms. The nurse should report the finding immediately and implement an
intervention.
