ATI Adult Medical-Surgical Nursing (CMS)
Practice Exam 2 Questions and Answers with
Rationales Latest Version
Question 1
A nurse is caring for a client admitted with acute heart failure exacerbation. Which finding
requires immediate intervention?
A. Weight gain of 2 lb in one week
B. Bilateral ankle edema
C. Oxygen saturation of 84%
D. Fatigue after activity
Correct Answer: C. Oxygen saturation of 84%
Expert Explanation
An oxygen saturation of 84% indicates severe hypoxemia and impaired oxygen delivery. The
priority is to address breathing problems first using the ABCs (Airway, Breathing,
Circulation).
Expected interventions:
• Apply oxygen as prescribed.
• Position in High Fowler’s position.
• Assess respiratory status.
• Administer prescribed medications such as diuretics.
Question 2
A nurse is caring for a client who has a central venous catheter. Which action reduces the risk
of infection?
A. Change the dressing only when visibly soiled.
B. Use sterile technique during dressing changes.
,C. Flush the catheter with tap water.
D. Remove the catheter daily for cleaning.
Correct Answer: B. Use sterile technique during dressing changes.
Expert Explanation
Central lines have a high risk of bloodstream infection. Strict sterile technique during insertion
and dressing changes reduces infection risk.
Additional prevention:
• Hand hygiene.
• Chlorhexidine skin preparation.
• Assess insertion site daily.
Question 3
A nurse is caring for a client with acute stroke symptoms. Which finding should the nurse
report immediately?
A. Mild headache
B. Sudden unilateral weakness
C. Blood pressure of 150/88 mm Hg
D. Difficulty sleeping
Correct Answer: B. Sudden unilateral weakness
Expert Explanation
Sudden unilateral weakness is a classic sign of an acute stroke.
Stroke warning signs:
• Facial drooping
• Arm weakness
• Speech difficulty
• Sudden vision changes
• Loss of coordination
Rapid intervention is necessary to determine eligibility for reperfusion therapy.
,Question 4
A nurse is teaching a client with COPD about oxygen therapy. Which statement indicates
understanding?
A. "I should increase oxygen flow whenever I feel short of breath."
B. "I will use oxygen exactly as prescribed."
C. "I should avoid pursed-lip breathing."
D. "I should lie flat when using oxygen."
Correct Answer: B. "I will use oxygen exactly as prescribed."
Expert Explanation
Clients with COPD should use oxygen at the prescribed flow rate. Excessive oxygen can worsen
carbon dioxide retention in some clients.
Teaching:
• Avoid changing oxygen settings without guidance.
• Use prescribed delivery devices.
• Practice breathing techniques.
Question 5
A nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect?
A. Bradycardia
B. Weight gain
C. Heat intolerance
D. Constipation
Correct Answer: C. Heat intolerance
Expert Explanation
Hyperthyroidism increases metabolic activity.
Expected findings:
• Heat intolerance
• Weight loss
, • Tachycardia
• Anxiety
• Increased appetite
• Diarrhea
Question 6
A nurse is caring for a client receiving warfarin therapy. Which laboratory value indicates the
need for further evaluation?
A. INR 2.5
B. INR 5.8
C. Hemoglobin 14 g/dL
D. Platelets 250,000/mm³
Correct Answer: B. INR 5.8
Expert Explanation
An excessively elevated INR increases the risk of serious bleeding.
Nursing priorities:
• Assess for bleeding.
• Hold medication if prescribed.
• Notify provider.
Question 7
A nurse is caring for a client with Clostridioides difficile infection (C. difficile). Which
infection-control measure is appropriate?
A. Use alcohol-based hand sanitizer after care.
B. Place the client on contact precautions.
C. Use airborne precautions.
D. Allow shared equipment between clients.
Correct Answer: B. Place the client on contact precautions.
Expert Explanation
Practice Exam 2 Questions and Answers with
Rationales Latest Version
Question 1
A nurse is caring for a client admitted with acute heart failure exacerbation. Which finding
requires immediate intervention?
A. Weight gain of 2 lb in one week
B. Bilateral ankle edema
C. Oxygen saturation of 84%
D. Fatigue after activity
Correct Answer: C. Oxygen saturation of 84%
Expert Explanation
An oxygen saturation of 84% indicates severe hypoxemia and impaired oxygen delivery. The
priority is to address breathing problems first using the ABCs (Airway, Breathing,
Circulation).
Expected interventions:
• Apply oxygen as prescribed.
• Position in High Fowler’s position.
• Assess respiratory status.
• Administer prescribed medications such as diuretics.
Question 2
A nurse is caring for a client who has a central venous catheter. Which action reduces the risk
of infection?
A. Change the dressing only when visibly soiled.
B. Use sterile technique during dressing changes.
,C. Flush the catheter with tap water.
D. Remove the catheter daily for cleaning.
Correct Answer: B. Use sterile technique during dressing changes.
Expert Explanation
Central lines have a high risk of bloodstream infection. Strict sterile technique during insertion
and dressing changes reduces infection risk.
Additional prevention:
• Hand hygiene.
• Chlorhexidine skin preparation.
• Assess insertion site daily.
Question 3
A nurse is caring for a client with acute stroke symptoms. Which finding should the nurse
report immediately?
A. Mild headache
B. Sudden unilateral weakness
C. Blood pressure of 150/88 mm Hg
D. Difficulty sleeping
Correct Answer: B. Sudden unilateral weakness
Expert Explanation
Sudden unilateral weakness is a classic sign of an acute stroke.
Stroke warning signs:
• Facial drooping
• Arm weakness
• Speech difficulty
• Sudden vision changes
• Loss of coordination
Rapid intervention is necessary to determine eligibility for reperfusion therapy.
,Question 4
A nurse is teaching a client with COPD about oxygen therapy. Which statement indicates
understanding?
A. "I should increase oxygen flow whenever I feel short of breath."
B. "I will use oxygen exactly as prescribed."
C. "I should avoid pursed-lip breathing."
D. "I should lie flat when using oxygen."
Correct Answer: B. "I will use oxygen exactly as prescribed."
Expert Explanation
Clients with COPD should use oxygen at the prescribed flow rate. Excessive oxygen can worsen
carbon dioxide retention in some clients.
Teaching:
• Avoid changing oxygen settings without guidance.
• Use prescribed delivery devices.
• Practice breathing techniques.
Question 5
A nurse is caring for a client with hyperthyroidism. Which finding should the nurse expect?
A. Bradycardia
B. Weight gain
C. Heat intolerance
D. Constipation
Correct Answer: C. Heat intolerance
Expert Explanation
Hyperthyroidism increases metabolic activity.
Expected findings:
• Heat intolerance
• Weight loss
, • Tachycardia
• Anxiety
• Increased appetite
• Diarrhea
Question 6
A nurse is caring for a client receiving warfarin therapy. Which laboratory value indicates the
need for further evaluation?
A. INR 2.5
B. INR 5.8
C. Hemoglobin 14 g/dL
D. Platelets 250,000/mm³
Correct Answer: B. INR 5.8
Expert Explanation
An excessively elevated INR increases the risk of serious bleeding.
Nursing priorities:
• Assess for bleeding.
• Hold medication if prescribed.
• Notify provider.
Question 7
A nurse is caring for a client with Clostridioides difficile infection (C. difficile). Which
infection-control measure is appropriate?
A. Use alcohol-based hand sanitizer after care.
B. Place the client on contact precautions.
C. Use airborne precautions.
D. Allow shared equipment between clients.
Correct Answer: B. Place the client on contact precautions.
Expert Explanation
