ATI RN ADULT MEDICAL SURGICAL EXAM QUESTIONS
AND 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,- myocrdial-
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.
A- nurse- is- caring- for- a- client- who- had- a- nephrostomy- tube- inserted- 112- hr- ago.-
Which- of- the- following- findings- should- the- nurse- report- to- the- provider?- --
CORRECT- ANSWERS-- - The- client- reports- back- pain
Rationale:- The- nurse- should- notify- the- provider- if- the- client- reports- back- pain,-
which- can- indicate- that- the- nephrostomy- tube- is- dislodged- or- clogged.
A- nurse- is- admitting- a- client- who- has- active- TB.- Which- of- the- following- types- of-
transmission- precautions- should- the- nurse- initiate?- -- CORRECT- ANSWERS-- - Airborne
Rationale:- Airborne- precautions- are- required- for- clients- who- have- infections- due- to-
micro-organisms- that- can- remain- suspended- in- air- for- lengthy- periods- of- time,- such-
as- tuberculosis,- measles,- varicella,- and- disseminated- varicella- zoster.
A- nurse- is- planning- care- for- a- client- who- has- a- sealed- radiation- implant- for-
cervical- cancer.- Which- of- the- following- interventions- should- the- nurse- include- in-
the- plan- of- care?- -- CORRECT- ANSWERS-- - Keep- a- lead-lined- container- in- the- client's-
room
Rationale:- The- nurse- should- keep- a- lead-lined- container- and- forceps- in- the- client's-
room- in- case- of- accidental- dislodgement- of- the- implant.
AND 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,- myocrdial-
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.
A- nurse- is- caring- for- a- client- who- had- a- nephrostomy- tube- inserted- 112- hr- ago.-
Which- of- the- following- findings- should- the- nurse- report- to- the- provider?- --
CORRECT- ANSWERS-- - The- client- reports- back- pain
Rationale:- The- nurse- should- notify- the- provider- if- the- client- reports- back- pain,-
which- can- indicate- that- the- nephrostomy- tube- is- dislodged- or- clogged.
A- nurse- is- admitting- a- client- who- has- active- TB.- Which- of- the- following- types- of-
transmission- precautions- should- the- nurse- initiate?- -- CORRECT- ANSWERS-- - Airborne
Rationale:- Airborne- precautions- are- required- for- clients- who- have- infections- due- to-
micro-organisms- that- can- remain- suspended- in- air- for- lengthy- periods- of- time,- such-
as- tuberculosis,- measles,- varicella,- and- disseminated- varicella- zoster.
A- nurse- is- planning- care- for- a- client- who- has- a- sealed- radiation- implant- for-
cervical- cancer.- Which- of- the- following- interventions- should- the- nurse- include- in-
the- plan- of- care?- -- CORRECT- ANSWERS-- - Keep- a- lead-lined- container- in- the- client's-
room
Rationale:- The- nurse- should- keep- a- lead-lined- container- and- forceps- in- the- client's-
room- in- case- of- accidental- dislodgement- of- the- implant.
