ATI MEDSURG RETAKE EXAM GUIDE
LATEST (2025)
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the
following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
, k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
, client dwho dhas da dchest dtube dto dclamp dthe dtube dand dprevent dair dfrom
dentering dthe dclient's dchest dif dthere dis dan dinterruption din dthe dsealed
ddrainage dsystem.
h. Communication dboard: dThe dnurse dshould densure da dcommunication dboard dis
dat dthedbedside dof da dclient dwho dhas daphasia dto dassist dthe dclient dwith
dcommunicating.
5. A dnurse dis dcaring dfor da dclient dwho dis dhaving da dseizure. dWhich dof dthe dfollowing dintervention dis dthe
dnurse’s dpriority?
a. Loosen dthe dclothing daround dthe dclient’s dneck
b. Check dthe dclient’s dpupillary dresponse
c. Turn dthe dclient dto dthe dside.
d. Move dfurniture daway dfrom dthe dclient
i. Loosen dthe dclothing daround dthe dclient's dneck: dThe dnurse dshould
dloosen danydrestrictive dclothing dthe dclient dis dwearing dto dprevent
dinjury dto dthe dclient. dHowever, danother daction dis dthe dpriority.
ii. Check dthe dclient's dpupillary dresponse: dThe dnurse dshould dperform
dneurologic dchecks dafter dthe dseizure dto dmonitor dthe dclient's drecovery.
dHowever, danotherdaction dis dthe dpriority.
iii. Turn dthe dclient dto dthe dside.: dThe dgreatest drisk dto dthis dclient dis dhypoxia
dfrom dan dimpaired dairway. dTherefore, dthe dpriority dintervention dthe
dnurse dshould dtake dis dto dplace dthe dclient din da dside-lying dposition dto
dprevent daspiration.
iv. Move dfurniture daway dfrom dthe dclient.: dAThe dnurse dshould dmove
dfurniture daway dfrom d the d client d to d prevent d self-injury. d However,
d another d action d is d the d priority.
6. A dnurse dis dproviding dteaching dto daclient dwho dhas dhypothyroidism dand dis dreceiving dlevothyroxine. dThe
dnurse dshoulddinstruct dthe dclient dthat dwhich dof dthe dfollowing dsupplements dcan dinterfere dwith dthe
deffectiveness dof dthe dmedication?
a. Ginkgo dbiloba
b. Glucosamine
c. Calcium
d. Vitamin dC
i.
Ginkgo dbiloba
ii. Ginkgo d biloba d reduces d the d pain d associated d with d peripheral d vascular
d disease dby dpromoting dvasodilation. dIt dcan dinteract dwith dmedications
dthat dhave danticoagulant dproperties, dbut dit dis dnot dknown dto dinterfere
dwith dthe dabsorptiondof dlevothyroxine.
iii. Glucosamine: dGlucosamine dtreats dosteoarthritis dby ddecreasing
dinflammationdand dstimulating dthe dbody's dproduction dof dsynovial dfluid
dand dcartilage. dIt dcan dinteract dwith dmedications dthat dhave dantiplatelet
, dor danticoagulant dproperties, dbut dit dis dnot dknown dto dinterfere dwith dthe
dabsorption dof dlevothyroxine.
iv. Calcium:NSWER
v. Calcium dlimits dthe ddevelopment dof dosteoporosis din dclients dwho dare
dpostmenopausal dand dworks das dan dantacid. dCalcium dsupplements dcan
dinterfere
with dthe dmetabolism dof da dnumber dof dmedications, dincluding
dlevothyroxine. dThednurse dshould dinstruct dthe dclient dto davoid dtaking
dcalcium dwithin d4 dhr dof dlevothyroxine dadministration.
vi. Vitamin dC: dVitamin dC dpromotes dwound dhealing. dIt dcan dcause da dfalse
dnegativedin dfecal doccult dblood dtests, dbut dit dis dnot dknown dto dinterfere
dwith dthe dabsorption
of d levothyroxine.
7. A dnurse dis dplanning dto dirrigate dand ddress da dclean, dgranulation dwound dfor da dclient dwho dhas da dpressure
dinjury. dWhichdof dthe dfollowing dactions dshould dthe dnurse dtake?
a. Apply da dwet-to-dry dgauze ddressing
b. Irrigate dwith dhydrogen dperoxide dsolution
c. Use da d30-ml dsyringe
d. Attach da d24-gauge dangiocatheter dto dthe dsyringe.
d 8.
a. Apply da d wet-to-dry d gauze d dressing.: d The d nurse d should d not d apply d wet-to-dry
d dressings dto d clean, d granulating d wounds das d they d interrupt d viable, d healing
d tissues d when d they d aredremoved. d Appropriate d dressings d for d a d wound d that d is
d developing d granulation d tissue dinclude da dhydrocolloid ddressing dand da
dtransparent dfilm ddressing.
b. Irrigate dwith dhydrogen dperoxide dsolution: dthe dnurse dshould duse dhydrogen
d peroxide d to dclean d contaminated d surfaces. d Hydrogen d peroxide d should d not d be
d used d on d a d pressure dinjury d wound d because d it d destroys d newly d granulated
d tissue. d Instead, d the d nurse d shouldduse d solutions d specifically d designed d as
d wound d cleansers d or d 0.9% d sodium d chloride dirrigation dto dirrigate dthe dwound.
c. Use da d30-mL dsyringe: dNSWERThe dnurse dshould duse da d30-mL dto d60-mL
dsyringe dwithdan d 18- dor d 19-gauge d catheter d to d deliver d the d ideal d pressure d of
d 8 d pounds d per d square dinch d(psi) dwhen dirrigating da dwound. dTo dmaintain
dhealthy dgranulation dtissue, dthe dwound dirrigation dshould dbe ddelivered dat
dbetween d4 dand d15 dpsi.
LATEST (2025)
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the
following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
, k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
, client dwho dhas da dchest dtube dto dclamp dthe dtube dand dprevent dair dfrom
dentering dthe dclient's dchest dif dthere dis dan dinterruption din dthe dsealed
ddrainage dsystem.
h. Communication dboard: dThe dnurse dshould densure da dcommunication dboard dis
dat dthedbedside dof da dclient dwho dhas daphasia dto dassist dthe dclient dwith
dcommunicating.
5. A dnurse dis dcaring dfor da dclient dwho dis dhaving da dseizure. dWhich dof dthe dfollowing dintervention dis dthe
dnurse’s dpriority?
a. Loosen dthe dclothing daround dthe dclient’s dneck
b. Check dthe dclient’s dpupillary dresponse
c. Turn dthe dclient dto dthe dside.
d. Move dfurniture daway dfrom dthe dclient
i. Loosen dthe dclothing daround dthe dclient's dneck: dThe dnurse dshould
dloosen danydrestrictive dclothing dthe dclient dis dwearing dto dprevent
dinjury dto dthe dclient. dHowever, danother daction dis dthe dpriority.
ii. Check dthe dclient's dpupillary dresponse: dThe dnurse dshould dperform
dneurologic dchecks dafter dthe dseizure dto dmonitor dthe dclient's drecovery.
dHowever, danotherdaction dis dthe dpriority.
iii. Turn dthe dclient dto dthe dside.: dThe dgreatest drisk dto dthis dclient dis dhypoxia
dfrom dan dimpaired dairway. dTherefore, dthe dpriority dintervention dthe
dnurse dshould dtake dis dto dplace dthe dclient din da dside-lying dposition dto
dprevent daspiration.
iv. Move dfurniture daway dfrom dthe dclient.: dAThe dnurse dshould dmove
dfurniture daway dfrom d the d client d to d prevent d self-injury. d However,
d another d action d is d the d priority.
6. A dnurse dis dproviding dteaching dto daclient dwho dhas dhypothyroidism dand dis dreceiving dlevothyroxine. dThe
dnurse dshoulddinstruct dthe dclient dthat dwhich dof dthe dfollowing dsupplements dcan dinterfere dwith dthe
deffectiveness dof dthe dmedication?
a. Ginkgo dbiloba
b. Glucosamine
c. Calcium
d. Vitamin dC
i.
Ginkgo dbiloba
ii. Ginkgo d biloba d reduces d the d pain d associated d with d peripheral d vascular
d disease dby dpromoting dvasodilation. dIt dcan dinteract dwith dmedications
dthat dhave danticoagulant dproperties, dbut dit dis dnot dknown dto dinterfere
dwith dthe dabsorptiondof dlevothyroxine.
iii. Glucosamine: dGlucosamine dtreats dosteoarthritis dby ddecreasing
dinflammationdand dstimulating dthe dbody's dproduction dof dsynovial dfluid
dand dcartilage. dIt dcan dinteract dwith dmedications dthat dhave dantiplatelet
, dor danticoagulant dproperties, dbut dit dis dnot dknown dto dinterfere dwith dthe
dabsorption dof dlevothyroxine.
iv. Calcium:NSWER
v. Calcium dlimits dthe ddevelopment dof dosteoporosis din dclients dwho dare
dpostmenopausal dand dworks das dan dantacid. dCalcium dsupplements dcan
dinterfere
with dthe dmetabolism dof da dnumber dof dmedications, dincluding
dlevothyroxine. dThednurse dshould dinstruct dthe dclient dto davoid dtaking
dcalcium dwithin d4 dhr dof dlevothyroxine dadministration.
vi. Vitamin dC: dVitamin dC dpromotes dwound dhealing. dIt dcan dcause da dfalse
dnegativedin dfecal doccult dblood dtests, dbut dit dis dnot dknown dto dinterfere
dwith dthe dabsorption
of d levothyroxine.
7. A dnurse dis dplanning dto dirrigate dand ddress da dclean, dgranulation dwound dfor da dclient dwho dhas da dpressure
dinjury. dWhichdof dthe dfollowing dactions dshould dthe dnurse dtake?
a. Apply da dwet-to-dry dgauze ddressing
b. Irrigate dwith dhydrogen dperoxide dsolution
c. Use da d30-ml dsyringe
d. Attach da d24-gauge dangiocatheter dto dthe dsyringe.
d 8.
a. Apply da d wet-to-dry d gauze d dressing.: d The d nurse d should d not d apply d wet-to-dry
d dressings dto d clean, d granulating d wounds das d they d interrupt d viable, d healing
d tissues d when d they d aredremoved. d Appropriate d dressings d for d a d wound d that d is
d developing d granulation d tissue dinclude da dhydrocolloid ddressing dand da
dtransparent dfilm ddressing.
b. Irrigate dwith dhydrogen dperoxide dsolution: dthe dnurse dshould duse dhydrogen
d peroxide d to dclean d contaminated d surfaces. d Hydrogen d peroxide d should d not d be
d used d on d a d pressure dinjury d wound d because d it d destroys d newly d granulated
d tissue. d Instead, d the d nurse d shouldduse d solutions d specifically d designed d as
d wound d cleansers d or d 0.9% d sodium d chloride dirrigation dto dirrigate dthe dwound.
c. Use da d30-mL dsyringe: dNSWERThe dnurse dshould duse da d30-mL dto d60-mL
dsyringe dwithdan d 18- dor d 19-gauge d catheter d to d deliver d the d ideal d pressure d of
d 8 d pounds d per d square dinch d(psi) dwhen dirrigating da dwound. dTo dmaintain
dhealthy dgranulation dtissue, dthe dwound dirrigation dshould dbe ddelivered dat
dbetween d4 dand d15 dpsi.
