RN Adult Medical-Surgical Nursing Content
Mastery Series Ed 12.0 (ATI CMS) 2026/2027 |
Medical-Surgical Nursing, NGN Clinical
Judgment & ATI Exam Prep | 100 Verified
Questions with Detailed Rationales
SECTION 1: EMERGENCY & CRITICAL CARE
(Questions 1-8)
Question 1
A nurse in the emergency department is caring for a client who fell
through the ice on a pond and is unresponsive and breathing slowly.
Which of the following actions should the nurse take? (Select all
that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Use a rapid rewarming water bath of 40°C to 42°C (104°F to 108°F)
E. Infuse warmed IV fluids
Answer: A, C, D, E
Rationale: For a client with hypothermia, remove wet clothing to prevent
further heat loss; apply warm blankets; use a warmed water bath for rapid
rewarming; and infuse warmed IV fluids to raise core temperature.
Maintaining normal room temperature is not sufficient rewarming .
,Question 2
A nurse in the emergency department is assessing a client who is
unresponsive. The client's partner states, "He was pulling weeds in
the yard and slumped to the ground." Which technique should the
nurse use to open the client's airway?
A. Head tilt, chin lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head
Answer: A. Head tilt, chin lift
Rationale: For an unresponsive client without suspected cervical spine
injury, the head tilt-chin lift maneuver is the appropriate technique to open
the airway. The modified jaw thrust is used when cervical spine injury is
suspected .
Question 3
A nurse is reviewing the common emergency management protocol
for a client who has asystole. Which action should the nurse plan to
take during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer epinephrine
D. Elevate the client's lower extremities
Answer: C. Administer epinephrine
Rationale: Asystole is a non-shockable rhythm; defibrillation is not indicated.
Epinephrine 1 mg IV/IO is administered every 3–5 minutes during asystole.
Transcutaneous pacing is not recommended for asystole .
Question 4
,A nurse on a medical-surgical unit should notify the rapid response
team for which of the following clients?
A. Client who has a pressure injury of the right heel whose blood glucose is
300 mg/dL
B. Client with new-onset confusion and respiratory rate of 8/min
C. Client with postoperative pain rated 6/10
D. Client with a temperature of 38°C (100.4°F)
Answer: B. Client with new-onset confusion and respiratory rate of 8/min
Rationale: A respiratory rate of 8/min is bradypnea and indicates respiratory
depression or failure requiring immediate intervention. New-onset confusion
suggests neurological compromise. Rapid response team activation criteria
typically include significant changes in respiratory rate, mental status, or
vital signs .
Question 5
A client is unresponsive following a traumatic head injury. The nurse
notes the client's pupils are unequal and sluggishly reactive. Which
condition should the nurse suspect?
A. Increased intracranial pressure (ICP) with herniation
B. Normal post-traumatic finding
C. Medication effect
D. Hypoglycemia
Answer: A. Increased intracranial pressure (ICP) with herniation
Rationale: Unequal pupils (anisocoria) with sluggish reactivity indicate
increased ICP, specifically uncal herniation compressing the oculomotor
nerve (CN III). This is a medical emergency requiring immediate notification
of the provider .
Question 6
, A nurse is caring for a client who experienced a traumatic head
injury and has an intraventricular catheter (ventriculostomy) for ICP
monitoring. The nurse should monitor for which complication
related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension
Answer: B. Infection
Rationale: Ventriculostomy is an invasive device that carries a significant
risk of infection (ventriculitis/meningitis). Strict aseptic technique is required
during care. Headache is expected with increased ICP but is not a
complication of the device itself .
Question 7
A nurse is caring for a client who was just informed of a new
diagnosis of breast cancer. Which statement reflects a lack of
understanding of an illness perspective?
A. "I have no family history of breast cancer."
B. "I need a second opinion. There is no lump."
C. "I am glad we live in the city near several large hospitals."
D. "I will schedule surgery next week, over the holidays."
Answer: B. "I need a second opinion. There is no lump."
Rationale: Denial of the diagnosis ("There is no lump") indicates a lack of
understanding of the illness perspective. This is a maladaptive coping
response that can delay treatment .
Question 8
Mastery Series Ed 12.0 (ATI CMS) 2026/2027 |
Medical-Surgical Nursing, NGN Clinical
Judgment & ATI Exam Prep | 100 Verified
Questions with Detailed Rationales
SECTION 1: EMERGENCY & CRITICAL CARE
(Questions 1-8)
Question 1
A nurse in the emergency department is caring for a client who fell
through the ice on a pond and is unresponsive and breathing slowly.
Which of the following actions should the nurse take? (Select all
that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Use a rapid rewarming water bath of 40°C to 42°C (104°F to 108°F)
E. Infuse warmed IV fluids
Answer: A, C, D, E
Rationale: For a client with hypothermia, remove wet clothing to prevent
further heat loss; apply warm blankets; use a warmed water bath for rapid
rewarming; and infuse warmed IV fluids to raise core temperature.
Maintaining normal room temperature is not sufficient rewarming .
,Question 2
A nurse in the emergency department is assessing a client who is
unresponsive. The client's partner states, "He was pulling weeds in
the yard and slumped to the ground." Which technique should the
nurse use to open the client's airway?
A. Head tilt, chin lift
B. Modified jaw thrust
C. Hyperextension of the head
D. Flexion of the head
Answer: A. Head tilt, chin lift
Rationale: For an unresponsive client without suspected cervical spine
injury, the head tilt-chin lift maneuver is the appropriate technique to open
the airway. The modified jaw thrust is used when cervical spine injury is
suspected .
Question 3
A nurse is reviewing the common emergency management protocol
for a client who has asystole. Which action should the nurse plan to
take during this cardiac emergency?
A. Perform defibrillation
B. Prepare for transcutaneous pacing
C. Administer epinephrine
D. Elevate the client's lower extremities
Answer: C. Administer epinephrine
Rationale: Asystole is a non-shockable rhythm; defibrillation is not indicated.
Epinephrine 1 mg IV/IO is administered every 3–5 minutes during asystole.
Transcutaneous pacing is not recommended for asystole .
Question 4
,A nurse on a medical-surgical unit should notify the rapid response
team for which of the following clients?
A. Client who has a pressure injury of the right heel whose blood glucose is
300 mg/dL
B. Client with new-onset confusion and respiratory rate of 8/min
C. Client with postoperative pain rated 6/10
D. Client with a temperature of 38°C (100.4°F)
Answer: B. Client with new-onset confusion and respiratory rate of 8/min
Rationale: A respiratory rate of 8/min is bradypnea and indicates respiratory
depression or failure requiring immediate intervention. New-onset confusion
suggests neurological compromise. Rapid response team activation criteria
typically include significant changes in respiratory rate, mental status, or
vital signs .
Question 5
A client is unresponsive following a traumatic head injury. The nurse
notes the client's pupils are unequal and sluggishly reactive. Which
condition should the nurse suspect?
A. Increased intracranial pressure (ICP) with herniation
B. Normal post-traumatic finding
C. Medication effect
D. Hypoglycemia
Answer: A. Increased intracranial pressure (ICP) with herniation
Rationale: Unequal pupils (anisocoria) with sluggish reactivity indicate
increased ICP, specifically uncal herniation compressing the oculomotor
nerve (CN III). This is a medical emergency requiring immediate notification
of the provider .
Question 6
, A nurse is caring for a client who experienced a traumatic head
injury and has an intraventricular catheter (ventriculostomy) for ICP
monitoring. The nurse should monitor for which complication
related to the ventriculostomy?
A. Headache
B. Infection
C. Aphasia
D. Hypertension
Answer: B. Infection
Rationale: Ventriculostomy is an invasive device that carries a significant
risk of infection (ventriculitis/meningitis). Strict aseptic technique is required
during care. Headache is expected with increased ICP but is not a
complication of the device itself .
Question 7
A nurse is caring for a client who was just informed of a new
diagnosis of breast cancer. Which statement reflects a lack of
understanding of an illness perspective?
A. "I have no family history of breast cancer."
B. "I need a second opinion. There is no lump."
C. "I am glad we live in the city near several large hospitals."
D. "I will schedule surgery next week, over the holidays."
Answer: B. "I need a second opinion. There is no lump."
Rationale: Denial of the diagnosis ("There is no lump") indicates a lack of
understanding of the illness perspective. This is a maladaptive coping
response that can delay treatment .
Question 8
