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ATI RN 231 Med-Surg Quiz 4 |
Questions and Correct Answers | 2026
Revised Update | 100% Correct
Section 1: Respiratory Disorders (Questions 1–10)
Q1: A nurse is caring for a client with COPD who has an SpO2 of 90% on room air. Which
oxygen delivery device and flow rate should the nurse initiate to maintain the client's target
oxygen saturation?
A. Nasal cannula at 4–6 L/min to achieve SpO2 of 95–100%
B. Venturi mask at 24–28% to titrate SpO2 to 88–92%
C. Nonrebreather mask at 10–15 L/min to achieve SpO2 >95%
D. Simple face mask at 6–8 L/min to titrate SpO2 to 90–94%
Correct Answer: B
Rationale: Correct because clients with COPD have chronic hypercapnia and rely on hypoxic
drive for ventilation; per ATI/NCLEX standards, oxygen should be titrated to maintain SpO2 of
88–92% using a precise delivery device such as a Venturi mask to avoid CO2 narcosis.
Standard nursing practice requires careful monitoring to prevent oxygen-induced
hypoventilation.
Q2: A client with asthma presents to the emergency department with an acute exacerbation.
The nurse notes the client is using accessory muscles and has a respiratory rate of 28. Which
is the priority nursing intervention?
A. Administer albuterol via nebulizer every 20 minutes for up to three doses
B. Initiate high-flow oxygen via nonrebreather at 15 L/min
C. Administer ipratropium bromide by MDI every 4 hours
D. Prepare the client for immediate endotracheal intubation
Correct Answer: A
Rationale: Correct because the priority intervention for an acute asthma exacerbation is
administration of a short-acting beta-agonist (SABA) such as albuterol via nebulizer every 20
minutes for up to three doses; per ATI/NCLEX standards, this is the first-line treatment to
, 2
reverse bronchospasm. Standard nursing practice requires reassessment of response after
each treatment and escalation to systemic corticosteroids if improvement is inadequate.
Q3: A nurse is reviewing the ABG results of a client admitted with pneumonia: pH 7.32,
PaCO2 52 mmHg, HCO3 26 mEq/L, PaO2 68 mmHg. Which interpretation is correct?
A. Respiratory alkalosis with partial compensation
B. Metabolic acidosis with full compensation
C. Respiratory acidosis without compensation
D. Metabolic alkalosis with respiratory compensation
Correct Answer: C
Rationale: Correct because the pH is low (<7.35) indicating acidosis, the PaCO2 is elevated
(>45 mmHg) indicating a respiratory cause, and the HCO3 is within normal range (22–26
mEq/L) indicating no metabolic compensation has occurred; per ATI/NCLEX standards, this
pattern reflects acute respiratory acidosis from hypoventilation. Standard nursing practice
requires identifying the underlying cause—in this case, pneumonia—and implementing
interventions to improve ventilation.
Q4: A client with a pulmonary embolism is receiving heparin therapy. The nurse reviews the
laboratory results and notes the aPTT is 90 seconds (control 30 seconds). Which action
should the nurse take?
A. Continue the current heparin infusion rate and recheck in 4 hours
B. Hold the heparin infusion and notify the provider
C. Increase the heparin infusion rate per protocol
D. Administer protamine sulfate immediately
Correct Answer: B
Rationale: Correct because the therapeutic aPTT range for heparin therapy is 1.5–2.5 times
the control value (45–75 seconds); per ATI/NCLEX standards, an aPTT of 90 seconds exceeds
the therapeutic range and indicates a bleeding risk, requiring the nurse to hold the infusion
and notify the provider. Standard nursing practice requires reassessment of the client for
signs of bleeding and adjustment of the heparin dose per protocol.
Q5: A nurse is caring for a client with active tuberculosis. Which infection control
precautions should the nurse implement?
A. Droplet precautions with a surgical mask within 3 feet of the client
B. Airborne precautions with an N95 respirator and negative pressure room
ATI RN 231 Med-Surg Quiz 4 |
Questions and Correct Answers | 2026
Revised Update | 100% Correct
Section 1: Respiratory Disorders (Questions 1–10)
Q1: A nurse is caring for a client with COPD who has an SpO2 of 90% on room air. Which
oxygen delivery device and flow rate should the nurse initiate to maintain the client's target
oxygen saturation?
A. Nasal cannula at 4–6 L/min to achieve SpO2 of 95–100%
B. Venturi mask at 24–28% to titrate SpO2 to 88–92%
C. Nonrebreather mask at 10–15 L/min to achieve SpO2 >95%
D. Simple face mask at 6–8 L/min to titrate SpO2 to 90–94%
Correct Answer: B
Rationale: Correct because clients with COPD have chronic hypercapnia and rely on hypoxic
drive for ventilation; per ATI/NCLEX standards, oxygen should be titrated to maintain SpO2 of
88–92% using a precise delivery device such as a Venturi mask to avoid CO2 narcosis.
Standard nursing practice requires careful monitoring to prevent oxygen-induced
hypoventilation.
Q2: A client with asthma presents to the emergency department with an acute exacerbation.
The nurse notes the client is using accessory muscles and has a respiratory rate of 28. Which
is the priority nursing intervention?
A. Administer albuterol via nebulizer every 20 minutes for up to three doses
B. Initiate high-flow oxygen via nonrebreather at 15 L/min
C. Administer ipratropium bromide by MDI every 4 hours
D. Prepare the client for immediate endotracheal intubation
Correct Answer: A
Rationale: Correct because the priority intervention for an acute asthma exacerbation is
administration of a short-acting beta-agonist (SABA) such as albuterol via nebulizer every 20
minutes for up to three doses; per ATI/NCLEX standards, this is the first-line treatment to
, 2
reverse bronchospasm. Standard nursing practice requires reassessment of response after
each treatment and escalation to systemic corticosteroids if improvement is inadequate.
Q3: A nurse is reviewing the ABG results of a client admitted with pneumonia: pH 7.32,
PaCO2 52 mmHg, HCO3 26 mEq/L, PaO2 68 mmHg. Which interpretation is correct?
A. Respiratory alkalosis with partial compensation
B. Metabolic acidosis with full compensation
C. Respiratory acidosis without compensation
D. Metabolic alkalosis with respiratory compensation
Correct Answer: C
Rationale: Correct because the pH is low (<7.35) indicating acidosis, the PaCO2 is elevated
(>45 mmHg) indicating a respiratory cause, and the HCO3 is within normal range (22–26
mEq/L) indicating no metabolic compensation has occurred; per ATI/NCLEX standards, this
pattern reflects acute respiratory acidosis from hypoventilation. Standard nursing practice
requires identifying the underlying cause—in this case, pneumonia—and implementing
interventions to improve ventilation.
Q4: A client with a pulmonary embolism is receiving heparin therapy. The nurse reviews the
laboratory results and notes the aPTT is 90 seconds (control 30 seconds). Which action
should the nurse take?
A. Continue the current heparin infusion rate and recheck in 4 hours
B. Hold the heparin infusion and notify the provider
C. Increase the heparin infusion rate per protocol
D. Administer protamine sulfate immediately
Correct Answer: B
Rationale: Correct because the therapeutic aPTT range for heparin therapy is 1.5–2.5 times
the control value (45–75 seconds); per ATI/NCLEX standards, an aPTT of 90 seconds exceeds
the therapeutic range and indicates a bleeding risk, requiring the nurse to hold the infusion
and notify the provider. Standard nursing practice requires reassessment of the client for
signs of bleeding and adjustment of the heparin dose per protocol.
Q5: A nurse is caring for a client with active tuberculosis. Which infection control
precautions should the nurse implement?
A. Droplet precautions with a surgical mask within 3 feet of the client
B. Airborne precautions with an N95 respirator and negative pressure room
