ATI MED-SURG II COMPREHENSIVE
PRACTICE EXAM |ACTUAL EXAM QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A nurse is caring for a client with heart failure who reports shortness of
breath when lying flat. Which intervention is most appropriate?
A. Encourage high fluid intake
B. Place the client in high-Fowler’s position
C. Assist the client to lie supine
D. Administer oxygen at 1 L/min via nasal cannula
Correct Answer: B
Rationale: High-Fowler’s position decreases preload and improves lung
expansion, reducing dyspnea associated with heart failure.
2. A client receiving IV heparin develops a nosebleed and bruising. Which
lab value is the nurse most likely to find abnormal?
A. Platelet count
B. Prothrombin time (PT)
C. Activated partial thromboplastin time (aPTT)
D. International normalized ratio (INR)
Correct Answer: C
Rationale: Heparin therapy is monitored with aPTT. Prolonged aPTT indicates
excessive anticoagulation and bleeding risk.
3. A client with type 1 diabetes mellitus is diaphoretic, shaky, and confused.
What is the nurse’s priority action?
A. Administer rapid-acting insulin
B. Check blood glucose level
C. Provide a high-protein snack
D. Encourage deep breathing
,Correct Answer: B
Rationale: Symptoms suggest hypoglycemia. Blood glucose must be checked
immediately before treatment.
4. A client post-abdominal surgery has absent bowel sounds 24 hours after
surgery. What should the nurse do?
A. Document as expected finding
B. Notify the provider immediately
C. Administer a laxative
D. Encourage fluid restriction
Correct Answer: A
Rationale: Absent bowel sounds within the first 24–48 hours after abdominal
surgery can be normal due to postoperative ileus.
5. A client with chronic kidney disease reports fatigue and muscle cramps.
Which electrolyte imbalance is most likely?
A. Hypokalemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypophosphatemia
Correct Answer: B
Rationale: Kidneys regulate potassium; impaired function causes
hyperkalemia, leading to muscle weakness and fatigue.
6. A client receiving furosemide reports muscle weakness. Which lab value
requires immediate attention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Magnesium 2.0 mg/dL
D. Calcium 9.5 mg/dL
, Correct Answer: B
Rationale: Hypokalemia (K⁺ < 3.5 mEq/L) is a dangerous side effect of loop
diuretics and can cause arrhythmias.
7. Which symptom indicates worsening respiratory status in a client with
pneumonia?
A. Productive cough
B. Crackles on auscultation
C. Increased respiratory rate from 18 to 34/min
D. Mild chest discomfort
Correct Answer: C
Rationale: Tachypnea suggests respiratory distress and decreased gas exchange.
8. A client with a chest tube suddenly shows continuous bubbling in the
water-seal chamber. What is the nurse’s priority action?
A. Clamp the chest tube immediately
B. Assess the tubing connections for air leak
C. Document the finding as normal
D. Increase suction pressure
Correct Answer: B
Rationale: Continuous bubbling indicates an air leak; the nurse should assess
for loose connections or system malfunction.
9. A client with cirrhosis develops ascites. Which diet prescription is
appropriate?
A. High sodium
B. Low protein
C. High potassium
D. Low sodium
Correct Answer: D
Rationale: Sodium restriction helps reduce fluid retention and ascites.
PRACTICE EXAM |ACTUAL EXAM QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A nurse is caring for a client with heart failure who reports shortness of
breath when lying flat. Which intervention is most appropriate?
A. Encourage high fluid intake
B. Place the client in high-Fowler’s position
C. Assist the client to lie supine
D. Administer oxygen at 1 L/min via nasal cannula
Correct Answer: B
Rationale: High-Fowler’s position decreases preload and improves lung
expansion, reducing dyspnea associated with heart failure.
2. A client receiving IV heparin develops a nosebleed and bruising. Which
lab value is the nurse most likely to find abnormal?
A. Platelet count
B. Prothrombin time (PT)
C. Activated partial thromboplastin time (aPTT)
D. International normalized ratio (INR)
Correct Answer: C
Rationale: Heparin therapy is monitored with aPTT. Prolonged aPTT indicates
excessive anticoagulation and bleeding risk.
3. A client with type 1 diabetes mellitus is diaphoretic, shaky, and confused.
What is the nurse’s priority action?
A. Administer rapid-acting insulin
B. Check blood glucose level
C. Provide a high-protein snack
D. Encourage deep breathing
,Correct Answer: B
Rationale: Symptoms suggest hypoglycemia. Blood glucose must be checked
immediately before treatment.
4. A client post-abdominal surgery has absent bowel sounds 24 hours after
surgery. What should the nurse do?
A. Document as expected finding
B. Notify the provider immediately
C. Administer a laxative
D. Encourage fluid restriction
Correct Answer: A
Rationale: Absent bowel sounds within the first 24–48 hours after abdominal
surgery can be normal due to postoperative ileus.
5. A client with chronic kidney disease reports fatigue and muscle cramps.
Which electrolyte imbalance is most likely?
A. Hypokalemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypophosphatemia
Correct Answer: B
Rationale: Kidneys regulate potassium; impaired function causes
hyperkalemia, leading to muscle weakness and fatigue.
6. A client receiving furosemide reports muscle weakness. Which lab value
requires immediate attention?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Magnesium 2.0 mg/dL
D. Calcium 9.5 mg/dL
, Correct Answer: B
Rationale: Hypokalemia (K⁺ < 3.5 mEq/L) is a dangerous side effect of loop
diuretics and can cause arrhythmias.
7. Which symptom indicates worsening respiratory status in a client with
pneumonia?
A. Productive cough
B. Crackles on auscultation
C. Increased respiratory rate from 18 to 34/min
D. Mild chest discomfort
Correct Answer: C
Rationale: Tachypnea suggests respiratory distress and decreased gas exchange.
8. A client with a chest tube suddenly shows continuous bubbling in the
water-seal chamber. What is the nurse’s priority action?
A. Clamp the chest tube immediately
B. Assess the tubing connections for air leak
C. Document the finding as normal
D. Increase suction pressure
Correct Answer: B
Rationale: Continuous bubbling indicates an air leak; the nurse should assess
for loose connections or system malfunction.
9. A client with cirrhosis develops ascites. Which diet prescription is
appropriate?
A. High sodium
B. Low protein
C. High potassium
D. Low sodium
Correct Answer: D
Rationale: Sodium restriction helps reduce fluid retention and ascites.
