ATI Med-Surg Proctored Exam NGN-Style
Questions, Case Scenario & Answers, 100%
Verified Graded A+
Question 1
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
Ceftriaxone. During data collection, the nurse notes the client is =ushed and the client
reports urticarial. After stopping the IV infusion, which of the following actions should
the nurse take first
Correct Answer
- Check the clients respirations
Question 1: A 68-year-old client with a history of heart failure is admitted with
acute decompensated heart failure. The nurse notes the client has 3+ pitting
edema in the lower extremities, crackles bilaterally, and reports orthopnea.
Which assessment finding should the nurse report to the provider as a priority
indicator of worsening condition?
A. Blood pressure of 142/88 mm Hg
B. Respiratory rate of 28 breaths/min with use of accessory muscles
C. Heart rate of 92 beats/min
D. Temperature of 37.2°C (99°F)
CORRECT ANSWER: B. Respiratory rate of 28 breaths/min with use of
accessory muscles
Rationale: Increased respiratory rate with accessory muscle use indicates respiratory
distress and potential progression toward respiratory failure, requiring immediate
intervention in a client with acute decompensated heart failure. The other findings
are less immediately life-threatening.
Question 2: A nurse is caring for a client who is 2 days postoperative following
a total hip arthroplasty. The client reports sudden onset of chest pain and
dyspnea. Which action should the nurse take first?
A. Administer prescribed analgesic
B. Elevate the head of the bed and apply oxygen
C. Notify the surgeon of possible wound infection
D. Encourage the client to perform ankle pumps
CORRECT ANSWER: B. Elevate the head of the bed and apply oxygen
Page 1 of 116
,Rationale: Sudden chest pain and dyspnea postoperatively raise concern for
pulmonary embolism. The priority is to optimize oxygenation and positioning while
preparing for further assessment and notification of the provider.
Question 3: A client with type 1 diabetes mellitus is admitted with diabetic
ketoacidosis. Which laboratory finding should the nurse expect?
A. Serum pH of 7.48
B. Blood glucose of 68 mg/dL
C. Serum bicarbonate of 14 mEq/L
D. Positive serum ketones with metabolic alkalosis
CORRECT ANSWER: C. Serum bicarbonate of 14 mEq/L
Rationale: Diabetic ketoacidosis produces metabolic acidosis characterized by low
serum bicarbonate, elevated blood glucose, and the presence of ketones. A pH of
7.48 and low glucose are inconsistent with DKA.
Question 4: A nurse is reviewing the plan of care for a client with chronic
kidney disease who is scheduled for hemodialysis. Which intervention should
the nurse include to protect the client’s arteriovenous fistula?
A. Obtain blood pressure readings in the arm with the fistula
B. Auscultate for a bruit and palpate for a thrill every shift
C. Use the fistula arm for intravenous medication administration
D. Encourage the client to sleep on the arm with the fistula
CORRECT ANSWER: B. Auscultate for a bruit and palpate for a thrill every shift
Rationale: Regular assessment of bruit and thrill confirms fistula patency. Blood
pressure measurement, venipuncture, and pressure on the fistula arm are
contraindicated because they can damage the access.
Question 5: A client with COPD is receiving oxygen therapy at 2 L/min via
nasal cannula. The nurse notes the client’s oxygen saturation is 88% and the
client is increasingly drowsy. Which action should the nurse take?
A. Increase the oxygen flow rate to 6 L/min
B. Encourage the client to take deep breaths and notify the provider
C. Remove the oxygen and place the client in high Fowler’s position
D. Administer a prescribed bronchodilator and reassess in 30 minutes
CORRECT ANSWER: B. Encourage the client to take deep breaths and notify
the provider
Rationale: Clients with COPD may retain CO2 when oxygen is increased excessively.
Drowsiness may indicate rising CO2 levels; the nurse should stimulate ventilation
and collaborate with the provider rather than autonomously increasing oxygen
significantly.
Page 2 of 116
,Question 6: A nurse is caring for a client who sustained a spinal cord injury at
T6. The client suddenly develops a severe headache, flushing, and
hypertension. Which action should the nurse take first?
A. Administer prescribed antihypertensive medication
B. Sit the client upright and check for bladder distention
C. Place the client in Trendelenburg position
D. Notify the provider of possible myocardial infarction
CORRECT ANSWER: B. Sit the client upright and check for bladder distention
Rationale: These signs indicate autonomic dysreflexia. The priority is to lower blood
pressure by sitting the client upright and removing the noxious stimulus, most
commonly bladder distention.
Question 7: A client is receiving continuous intravenous heparin for a deep
vein thrombosis. Which laboratory value requires immediate notification of
the provider?
A. aPTT of 65 seconds
B. Platelet count of 95,000/mm³
C. INR of 1.1
D. Hemoglobin of 13.2 g/dL
CORRECT ANSWER: B. Platelet count of 95,000/mm³
Rationale: A significant drop in platelet count may indicate heparin-induced
thrombocytopenia, a serious complication requiring immediate discontinuation of
heparin and provider notification.
Question 8: A nurse is teaching a client who has a new prescription for
warfarin. Which statement by the client indicates a need for further teaching?
A. “I will have my INR checked regularly.”
B. “I will use a soft-bristle toothbrush.”
C. “I will take aspirin if I develop a headache.”
D. “I will avoid foods high in vitamin K in large amounts.”
CORRECT ANSWER: C. “I will take aspirin if I develop a headache.”
Rationale: Aspirin increases bleeding risk when taken with warfarin. Clients should
avoid NSAIDs and aspirin unless specifically prescribed and should report
headaches that could indicate bleeding.
Question 9: A client with acute pancreatitis is admitted. Which assessment
finding should the nurse expect?
A. Left lower quadrant pain relieved by eating
B. Epigastric pain radiating to the back, worsened by lying supine
C. Right upper quadrant pain with jaundice
Page 3 of 116
, D. Periumbilical pain with rebound tenderness only
CORRECT ANSWER: B. Epigastric pain radiating to the back, worsened by lying
supine
Rationale: Classic presentation of acute pancreatitis includes severe epigastric pain
that radiates to the back and is aggravated by lying flat; clients often prefer the fetal
position for relief.
Question 10: A nurse is caring for a client who is postoperative following a
thyroidectomy. Which finding requires immediate intervention?
A. Hoarseness when speaking
B. Tingling around the mouth and fingertips
C. Temperature of 37.4°C (99.3°F)
D. Serosanguineous drainage on the dressing
CORRECT ANSWER: B. Tingling around the mouth and fingertips
Rationale: Circumoral and fingertip tingling suggests hypocalcemia from possible
parathyroid gland injury, which can progress to tetany and laryngospasm; calcium
gluconate should be available.
Question 11: A client with pneumonia has an oxygen saturation of 90% on
room air and is receiving antibiotics. Which intervention should the nurse
implement to improve gas exchange?
A. Encourage bed rest in the supine position
B. Assist the client to a high Fowler’s position and encourage incentive spirometry
C. Restrict fluid intake to 1,000 mL/day
D. Administer a cough suppressant every 4 hours
CORRECT ANSWER: B. Assist the client to a high Fowler’s position and
encourage incentive spirometry
Rationale: High Fowler’s position optimizes lung expansion, and incentive
spirometry promotes deep breathing and secretion clearance, improving
oxygenation in pneumonia.
Question 12: A nurse is reviewing laboratory results for a client with cirrhosis.
Which finding is most consistent with the diagnosis?
A. Elevated serum albumin
B. Decreased prothrombin time
C. Elevated ammonia level
D. Decreased bilirubin
CORRECT ANSWER: C. Elevated ammonia level
Page 4 of 116
Questions, Case Scenario & Answers, 100%
Verified Graded A+
Question 1
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
Ceftriaxone. During data collection, the nurse notes the client is =ushed and the client
reports urticarial. After stopping the IV infusion, which of the following actions should
the nurse take first
Correct Answer
- Check the clients respirations
Question 1: A 68-year-old client with a history of heart failure is admitted with
acute decompensated heart failure. The nurse notes the client has 3+ pitting
edema in the lower extremities, crackles bilaterally, and reports orthopnea.
Which assessment finding should the nurse report to the provider as a priority
indicator of worsening condition?
A. Blood pressure of 142/88 mm Hg
B. Respiratory rate of 28 breaths/min with use of accessory muscles
C. Heart rate of 92 beats/min
D. Temperature of 37.2°C (99°F)
CORRECT ANSWER: B. Respiratory rate of 28 breaths/min with use of
accessory muscles
Rationale: Increased respiratory rate with accessory muscle use indicates respiratory
distress and potential progression toward respiratory failure, requiring immediate
intervention in a client with acute decompensated heart failure. The other findings
are less immediately life-threatening.
Question 2: A nurse is caring for a client who is 2 days postoperative following
a total hip arthroplasty. The client reports sudden onset of chest pain and
dyspnea. Which action should the nurse take first?
A. Administer prescribed analgesic
B. Elevate the head of the bed and apply oxygen
C. Notify the surgeon of possible wound infection
D. Encourage the client to perform ankle pumps
CORRECT ANSWER: B. Elevate the head of the bed and apply oxygen
Page 1 of 116
,Rationale: Sudden chest pain and dyspnea postoperatively raise concern for
pulmonary embolism. The priority is to optimize oxygenation and positioning while
preparing for further assessment and notification of the provider.
Question 3: A client with type 1 diabetes mellitus is admitted with diabetic
ketoacidosis. Which laboratory finding should the nurse expect?
A. Serum pH of 7.48
B. Blood glucose of 68 mg/dL
C. Serum bicarbonate of 14 mEq/L
D. Positive serum ketones with metabolic alkalosis
CORRECT ANSWER: C. Serum bicarbonate of 14 mEq/L
Rationale: Diabetic ketoacidosis produces metabolic acidosis characterized by low
serum bicarbonate, elevated blood glucose, and the presence of ketones. A pH of
7.48 and low glucose are inconsistent with DKA.
Question 4: A nurse is reviewing the plan of care for a client with chronic
kidney disease who is scheduled for hemodialysis. Which intervention should
the nurse include to protect the client’s arteriovenous fistula?
A. Obtain blood pressure readings in the arm with the fistula
B. Auscultate for a bruit and palpate for a thrill every shift
C. Use the fistula arm for intravenous medication administration
D. Encourage the client to sleep on the arm with the fistula
CORRECT ANSWER: B. Auscultate for a bruit and palpate for a thrill every shift
Rationale: Regular assessment of bruit and thrill confirms fistula patency. Blood
pressure measurement, venipuncture, and pressure on the fistula arm are
contraindicated because they can damage the access.
Question 5: A client with COPD is receiving oxygen therapy at 2 L/min via
nasal cannula. The nurse notes the client’s oxygen saturation is 88% and the
client is increasingly drowsy. Which action should the nurse take?
A. Increase the oxygen flow rate to 6 L/min
B. Encourage the client to take deep breaths and notify the provider
C. Remove the oxygen and place the client in high Fowler’s position
D. Administer a prescribed bronchodilator and reassess in 30 minutes
CORRECT ANSWER: B. Encourage the client to take deep breaths and notify
the provider
Rationale: Clients with COPD may retain CO2 when oxygen is increased excessively.
Drowsiness may indicate rising CO2 levels; the nurse should stimulate ventilation
and collaborate with the provider rather than autonomously increasing oxygen
significantly.
Page 2 of 116
,Question 6: A nurse is caring for a client who sustained a spinal cord injury at
T6. The client suddenly develops a severe headache, flushing, and
hypertension. Which action should the nurse take first?
A. Administer prescribed antihypertensive medication
B. Sit the client upright and check for bladder distention
C. Place the client in Trendelenburg position
D. Notify the provider of possible myocardial infarction
CORRECT ANSWER: B. Sit the client upright and check for bladder distention
Rationale: These signs indicate autonomic dysreflexia. The priority is to lower blood
pressure by sitting the client upright and removing the noxious stimulus, most
commonly bladder distention.
Question 7: A client is receiving continuous intravenous heparin for a deep
vein thrombosis. Which laboratory value requires immediate notification of
the provider?
A. aPTT of 65 seconds
B. Platelet count of 95,000/mm³
C. INR of 1.1
D. Hemoglobin of 13.2 g/dL
CORRECT ANSWER: B. Platelet count of 95,000/mm³
Rationale: A significant drop in platelet count may indicate heparin-induced
thrombocytopenia, a serious complication requiring immediate discontinuation of
heparin and provider notification.
Question 8: A nurse is teaching a client who has a new prescription for
warfarin. Which statement by the client indicates a need for further teaching?
A. “I will have my INR checked regularly.”
B. “I will use a soft-bristle toothbrush.”
C. “I will take aspirin if I develop a headache.”
D. “I will avoid foods high in vitamin K in large amounts.”
CORRECT ANSWER: C. “I will take aspirin if I develop a headache.”
Rationale: Aspirin increases bleeding risk when taken with warfarin. Clients should
avoid NSAIDs and aspirin unless specifically prescribed and should report
headaches that could indicate bleeding.
Question 9: A client with acute pancreatitis is admitted. Which assessment
finding should the nurse expect?
A. Left lower quadrant pain relieved by eating
B. Epigastric pain radiating to the back, worsened by lying supine
C. Right upper quadrant pain with jaundice
Page 3 of 116
, D. Periumbilical pain with rebound tenderness only
CORRECT ANSWER: B. Epigastric pain radiating to the back, worsened by lying
supine
Rationale: Classic presentation of acute pancreatitis includes severe epigastric pain
that radiates to the back and is aggravated by lying flat; clients often prefer the fetal
position for relief.
Question 10: A nurse is caring for a client who is postoperative following a
thyroidectomy. Which finding requires immediate intervention?
A. Hoarseness when speaking
B. Tingling around the mouth and fingertips
C. Temperature of 37.4°C (99.3°F)
D. Serosanguineous drainage on the dressing
CORRECT ANSWER: B. Tingling around the mouth and fingertips
Rationale: Circumoral and fingertip tingling suggests hypocalcemia from possible
parathyroid gland injury, which can progress to tetany and laryngospasm; calcium
gluconate should be available.
Question 11: A client with pneumonia has an oxygen saturation of 90% on
room air and is receiving antibiotics. Which intervention should the nurse
implement to improve gas exchange?
A. Encourage bed rest in the supine position
B. Assist the client to a high Fowler’s position and encourage incentive spirometry
C. Restrict fluid intake to 1,000 mL/day
D. Administer a cough suppressant every 4 hours
CORRECT ANSWER: B. Assist the client to a high Fowler’s position and
encourage incentive spirometry
Rationale: High Fowler’s position optimizes lung expansion, and incentive
spirometry promotes deep breathing and secretion clearance, improving
oxygenation in pneumonia.
Question 12: A nurse is reviewing laboratory results for a client with cirrhosis.
Which finding is most consistent with the diagnosis?
A. Elevated serum albumin
B. Decreased prothrombin time
C. Elevated ammonia level
D. Decreased bilirubin
CORRECT ANSWER: C. Elevated ammonia level
Page 4 of 116
