ATI Med-Surg Proctored Exam Test Bank 2026 |
Medical-Surgical Nursing, NCLEX Preparation |
Multiple Choice Questions and Answers with Verified
Rationales | Get HighScore | Instant Download
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled
ventilation with FiO2 0.8, PEEP 10 cm H2O, and plateau pressure 32 cm H2O. Arterial
blood gas shows pH 7.25, PaCO2 50 mm Hg, PaO2 55 mm Hg. Which intervention should
the nurse expect next?
A. Increase PEEP to 15 cm H2O and recruit with sustained inflation
B. Switch to pressure-controlled ventilation with inverse ratio
C. Administer neuromuscular blockade and prone positioning
D. Decrease tidal volume to 4 mL/kg ideal body weight
Answer: C
Rationale: Neuromuscular blockade and prone positioning improve oxygenation in refractory
ARDS by reducing V/Q mismatch and redistributing pulmonary blood flow. Increasing PEEP
may worsen hyperinflation given high plateau pressure. Inverse ratio ventilation is not first-line.
Decreasing tidal volume further may cause hypoventilation.
2. A nurse reviews a patient's laboratory results: serum sodium 128 mEq/L, serum
potassium 3.2 mEq/L, serum osmolality 260 mOsm/kg, urine osmolality 600 mOsm/kg,
urine sodium 40 mEq/L. The patient has small cell lung cancer. Which condition is most
likely?
A. Cerebral salt wasting
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Adrenal insufficiency
D. Psychogenic polydipsia
Answer: B
Rationale: Hyponatremia with low serum osmolality, high urine osmolality (>100), and urine
sodium >20 in a patient with small cell lung cancer (ectopic ADH) is classic SIADH. Cerebral
salt wasting presents with high urine sodium but hypovolemia. Adrenal insufficiency has
hyperkalemia. Psychogenic polydipsia has low urine osmolality.
Page 1
,3. A patient with cirrhosis and ascites develops confusion, asterixis, and elevated serum
ammonia. The provider orders lactulose 30 mL every 6 hours. Which assessment finding
indicates therapeutic effectiveness?
A. Two to three soft stools per day
B. Urine output >30 mL/hour
C. Serum ammonia level <20 mcg/dL
D. Decreased abdominal girth
Answer: A
Rationale: Lactulose works by acidifying the colon, trapping ammonium in the stool, and
promoting its excretion. The goal is 2-3 soft stools daily; excessive diarrhea can cause
dehydration and electrolyte imbalances. Serum ammonia correlates poorly with clinical status.
Decreased abdominal girth reflects diuresis, not lactulose effect.
4. A nurse is caring for a patient with diabetic ketoacidosis (DKA) receiving intravenous
insulin at 0.1 units/kg/hour. The patient's serum potassium is 3.0 mEq/L. Which action
should the nurse take?
A. Continue insulin infusion and monitor potassium hourly
B. Stop insulin infusion and administer intravenous potassium
C. Administer potassium chloride 40 mEq IV piggyback over 2 hours
D. Hold insulin and recheck potassium in 1 hour
Answer: C
Rationale: In DKA, insulin drives potassium into cells, worsening hypokalemia. With potassium
<3.3 mEq/L, insulin should be held until potassium is corrected to avoid life-threatening
arrhythmias. However, the question states the patient is already receiving insulin; the nurse
should administer potassium while continuing insulin cautiously. Guidelines recommend
potassium replacement when K+ <3.3, and insulin may be temporarily held if K+ <3.0. Option
C is the best answer: administer potassium and continue insulin (since insulin is already
running). But many protocols hold insulin if K+ <3.0. Given the options, C is most appropriate:
replace potassium, then continue insulin.
5. A patient with a history of heart failure and chronic kidney disease (GFR 30 mL/min) is
prescribed metformin for type 2 diabetes. Which action should the nurse take?
A. Administer metformin as ordered without adjustment
B. Hold metformin and notify the provider of contraindication
C. Reduce metformin dose by 50% and monitor renal function
D. Administer metformin with a low-iodine contrast dye precaution
Answer: B
Rationale: Metformin is contraindicated when GFR <30 mL/min due to risk of lactic acidosis.
The nurse should hold the medication and notify the provider. Dose reduction is recommended
for GFR 30-45, but not below 30. Contrast dye precaution is relevant for GFR <60, but the
primary issue is metformin itself.
Page 2
,6. A patient with septic shock is receiving norepinephrine at 20 mcg/min and has a mean
arterial pressure (MAP) of 58 mm Hg. The provider orders a second vasopressor. Which
agent should the nurse anticipate?
A. Dopamine
B. Epinephrine
C. Vasopressin
D. Phenylephrine
Answer: C
Rationale: Surviving Sepsis Campaign guidelines recommend adding vasopressin (0.03
units/min) when MAP remains inadequate despite norepinephrine. Vasopressin reduces
catecholamine requirements and has a different mechanism. Epinephrine is an alternative but
increases myocardial oxygen demand. Dopamine has more arrhythmias. Phenylephrine is pure
alpha, less preferred.
7. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 28
mm Hg and cerebral perfusion pressure (CPP) of 50 mm Hg. Which intervention should
the nurse implement first?
A. Administer mannitol 0.5 g/kg IV bolus
B. Increase sedation with propofol drip
C. Elevate head of bed to 30 degrees
D. Hyperventilate to PaCO2 30 mm Hg
Answer: C
Rationale: Elevating the head of bed to 30 degrees promotes venous drainage and reduces ICP,
improving CPP. It is a simple, non-invasive first step. Mannitol is indicated for acute ICP
elevation but after basic measures. Hyperventilation can cause ischemia and is reserved for
herniation. Sedation may lower MAP, worsening CPP.
8. A patient with acute pancreatitis has a serum calcium of 7.2 mg/dL (corrected for
albumin). Which complication does this finding most likely indicate?
A. Pancreatic necrosis with saponification
B. Acute kidney injury with hyperphosphatemia
C. Hypoparathyroidism due to thyroid involvement
D. Malabsorption secondary to pancreatic insufficiency
Answer: A
Rationale: Hypocalcemia in acute pancreatitis is caused by saponification (calcium binding to
free fatty acids in necrotic fat), indicating severe disease and pancreatic necrosis. It is a marker
of poor prognosis (Ranson criteria). Kidney injury may contribute but not primary.
Hypoparathyroidism is rare. Malabsorption is chronic.
Page 3
, 9. A patient with stage IV chronic kidney disease (GFR 20 mL/min) is scheduled for an
elective surgery. The provider orders enoxaparin 40 mg subcutaneously daily for DVT
prophylaxis. Which action should the nurse take?
A. Administer enoxaparin as ordered
B. Hold enoxaparin and notify provider about renal dose adjustment
C. Give half the dose (20 mg) due to renal impairment
D. Administer unfractionated heparin instead of enoxaparin
Answer: B
Rationale: Enoxaparin is cleared renally; with GFR <30 mL/min, dose reduction (e.g., 30 mg
daily) is recommended, not standard 40 mg. The nurse should hold and clarify the dose.
Unfractionated heparin is preferred in severe renal impairment but not automatically. Half-dose
is not standard without order.
10. A patient with a history of multiple blood transfusions develops sudden hypotension,
urticaria, and wheezing during a platelet transfusion. The nurse stops the transfusion and
starts IV fluids. Which medication should the nurse administer first?
A. Diphenhydramine 50 mg IV
B. Epinephrine 0.3 mg IM
C. Methylprednisolone 125 mg IV
D. Albuterol nebulized
Answer: B
Rationale: The presentation is anaphylaxis (hypotension, urticaria, wheezing). First-line
treatment is intramuscular epinephrine (0.3 mg) for vasoconstriction and bronchodilation.
Diphenhydramine and steroids are adjunctive. Albuterol treats bronchospasm but not
hypotension. Epinephrine is life-saving and should be given first.
11. A patient with heart failure develops acute pulmonary edema. Which intervention
should the nurse anticipate as most effective for rapidly reducing preload and improving
oxygenation?
A. Administer intravenous furosemide 40 mg bolus
B. Apply non-invasive positive pressure ventilation (NIPPV)
C. Position the patient in high Fowler's with legs dependent
D. Initiate intravenous nitroglycerin infusion at 10 mcg/min
Answer: B
Rationale: NIPPV (CPAP or BiPAP) rapidly reduces preload by increasing intrathoracic
pressure and improves oxygenation by recruiting alveoli, making it the most effective initial
intervention. Furosemide reduces preload but has slower onset. Nitroglycerin is a venodilator
but may not be as rapid. Positioning helps but is less effective alone.
Page 4
Medical-Surgical Nursing, NCLEX Preparation |
Multiple Choice Questions and Answers with Verified
Rationales | Get HighScore | Instant Download
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled
ventilation with FiO2 0.8, PEEP 10 cm H2O, and plateau pressure 32 cm H2O. Arterial
blood gas shows pH 7.25, PaCO2 50 mm Hg, PaO2 55 mm Hg. Which intervention should
the nurse expect next?
A. Increase PEEP to 15 cm H2O and recruit with sustained inflation
B. Switch to pressure-controlled ventilation with inverse ratio
C. Administer neuromuscular blockade and prone positioning
D. Decrease tidal volume to 4 mL/kg ideal body weight
Answer: C
Rationale: Neuromuscular blockade and prone positioning improve oxygenation in refractory
ARDS by reducing V/Q mismatch and redistributing pulmonary blood flow. Increasing PEEP
may worsen hyperinflation given high plateau pressure. Inverse ratio ventilation is not first-line.
Decreasing tidal volume further may cause hypoventilation.
2. A nurse reviews a patient's laboratory results: serum sodium 128 mEq/L, serum
potassium 3.2 mEq/L, serum osmolality 260 mOsm/kg, urine osmolality 600 mOsm/kg,
urine sodium 40 mEq/L. The patient has small cell lung cancer. Which condition is most
likely?
A. Cerebral salt wasting
B. Syndrome of inappropriate antidiuretic hormone (SIADH)
C. Adrenal insufficiency
D. Psychogenic polydipsia
Answer: B
Rationale: Hyponatremia with low serum osmolality, high urine osmolality (>100), and urine
sodium >20 in a patient with small cell lung cancer (ectopic ADH) is classic SIADH. Cerebral
salt wasting presents with high urine sodium but hypovolemia. Adrenal insufficiency has
hyperkalemia. Psychogenic polydipsia has low urine osmolality.
Page 1
,3. A patient with cirrhosis and ascites develops confusion, asterixis, and elevated serum
ammonia. The provider orders lactulose 30 mL every 6 hours. Which assessment finding
indicates therapeutic effectiveness?
A. Two to three soft stools per day
B. Urine output >30 mL/hour
C. Serum ammonia level <20 mcg/dL
D. Decreased abdominal girth
Answer: A
Rationale: Lactulose works by acidifying the colon, trapping ammonium in the stool, and
promoting its excretion. The goal is 2-3 soft stools daily; excessive diarrhea can cause
dehydration and electrolyte imbalances. Serum ammonia correlates poorly with clinical status.
Decreased abdominal girth reflects diuresis, not lactulose effect.
4. A nurse is caring for a patient with diabetic ketoacidosis (DKA) receiving intravenous
insulin at 0.1 units/kg/hour. The patient's serum potassium is 3.0 mEq/L. Which action
should the nurse take?
A. Continue insulin infusion and monitor potassium hourly
B. Stop insulin infusion and administer intravenous potassium
C. Administer potassium chloride 40 mEq IV piggyback over 2 hours
D. Hold insulin and recheck potassium in 1 hour
Answer: C
Rationale: In DKA, insulin drives potassium into cells, worsening hypokalemia. With potassium
<3.3 mEq/L, insulin should be held until potassium is corrected to avoid life-threatening
arrhythmias. However, the question states the patient is already receiving insulin; the nurse
should administer potassium while continuing insulin cautiously. Guidelines recommend
potassium replacement when K+ <3.3, and insulin may be temporarily held if K+ <3.0. Option
C is the best answer: administer potassium and continue insulin (since insulin is already
running). But many protocols hold insulin if K+ <3.0. Given the options, C is most appropriate:
replace potassium, then continue insulin.
5. A patient with a history of heart failure and chronic kidney disease (GFR 30 mL/min) is
prescribed metformin for type 2 diabetes. Which action should the nurse take?
A. Administer metformin as ordered without adjustment
B. Hold metformin and notify the provider of contraindication
C. Reduce metformin dose by 50% and monitor renal function
D. Administer metformin with a low-iodine contrast dye precaution
Answer: B
Rationale: Metformin is contraindicated when GFR <30 mL/min due to risk of lactic acidosis.
The nurse should hold the medication and notify the provider. Dose reduction is recommended
for GFR 30-45, but not below 30. Contrast dye precaution is relevant for GFR <60, but the
primary issue is metformin itself.
Page 2
,6. A patient with septic shock is receiving norepinephrine at 20 mcg/min and has a mean
arterial pressure (MAP) of 58 mm Hg. The provider orders a second vasopressor. Which
agent should the nurse anticipate?
A. Dopamine
B. Epinephrine
C. Vasopressin
D. Phenylephrine
Answer: C
Rationale: Surviving Sepsis Campaign guidelines recommend adding vasopressin (0.03
units/min) when MAP remains inadequate despite norepinephrine. Vasopressin reduces
catecholamine requirements and has a different mechanism. Epinephrine is an alternative but
increases myocardial oxygen demand. Dopamine has more arrhythmias. Phenylephrine is pure
alpha, less preferred.
7. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 28
mm Hg and cerebral perfusion pressure (CPP) of 50 mm Hg. Which intervention should
the nurse implement first?
A. Administer mannitol 0.5 g/kg IV bolus
B. Increase sedation with propofol drip
C. Elevate head of bed to 30 degrees
D. Hyperventilate to PaCO2 30 mm Hg
Answer: C
Rationale: Elevating the head of bed to 30 degrees promotes venous drainage and reduces ICP,
improving CPP. It is a simple, non-invasive first step. Mannitol is indicated for acute ICP
elevation but after basic measures. Hyperventilation can cause ischemia and is reserved for
herniation. Sedation may lower MAP, worsening CPP.
8. A patient with acute pancreatitis has a serum calcium of 7.2 mg/dL (corrected for
albumin). Which complication does this finding most likely indicate?
A. Pancreatic necrosis with saponification
B. Acute kidney injury with hyperphosphatemia
C. Hypoparathyroidism due to thyroid involvement
D. Malabsorption secondary to pancreatic insufficiency
Answer: A
Rationale: Hypocalcemia in acute pancreatitis is caused by saponification (calcium binding to
free fatty acids in necrotic fat), indicating severe disease and pancreatic necrosis. It is a marker
of poor prognosis (Ranson criteria). Kidney injury may contribute but not primary.
Hypoparathyroidism is rare. Malabsorption is chronic.
Page 3
, 9. A patient with stage IV chronic kidney disease (GFR 20 mL/min) is scheduled for an
elective surgery. The provider orders enoxaparin 40 mg subcutaneously daily for DVT
prophylaxis. Which action should the nurse take?
A. Administer enoxaparin as ordered
B. Hold enoxaparin and notify provider about renal dose adjustment
C. Give half the dose (20 mg) due to renal impairment
D. Administer unfractionated heparin instead of enoxaparin
Answer: B
Rationale: Enoxaparin is cleared renally; with GFR <30 mL/min, dose reduction (e.g., 30 mg
daily) is recommended, not standard 40 mg. The nurse should hold and clarify the dose.
Unfractionated heparin is preferred in severe renal impairment but not automatically. Half-dose
is not standard without order.
10. A patient with a history of multiple blood transfusions develops sudden hypotension,
urticaria, and wheezing during a platelet transfusion. The nurse stops the transfusion and
starts IV fluids. Which medication should the nurse administer first?
A. Diphenhydramine 50 mg IV
B. Epinephrine 0.3 mg IM
C. Methylprednisolone 125 mg IV
D. Albuterol nebulized
Answer: B
Rationale: The presentation is anaphylaxis (hypotension, urticaria, wheezing). First-line
treatment is intramuscular epinephrine (0.3 mg) for vasoconstriction and bronchodilation.
Diphenhydramine and steroids are adjunctive. Albuterol treats bronchospasm but not
hypotension. Epinephrine is life-saving and should be given first.
11. A patient with heart failure develops acute pulmonary edema. Which intervention
should the nurse anticipate as most effective for rapidly reducing preload and improving
oxygenation?
A. Administer intravenous furosemide 40 mg bolus
B. Apply non-invasive positive pressure ventilation (NIPPV)
C. Position the patient in high Fowler's with legs dependent
D. Initiate intravenous nitroglycerin infusion at 10 mcg/min
Answer: B
Rationale: NIPPV (CPAP or BiPAP) rapidly reduces preload by increasing intrathoracic
pressure and improves oxygenation by recruiting alveoli, making it the most effective initial
intervention. Furosemide reduces preload but has slower onset. Nitroglycerin is a venodilator
but may not be as rapid. Positioning helps but is less effective alone.
Page 4
