ATI MED-SURG PROCTORED EXAM TEST BANK
COMPREHENSIVE Questions and Correct Answers
(Verified Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1.
A nurse is caring for a client who has acute heart failure and reports
increasing shortness of breath. Which assessment finding requires
immediate intervention?
A. 1+ bilateral ankle edema
B. Heart rate of 96/min
C. Oxygen saturation of 88% on room air
D. Blood pressure of 138/84 mm Hg
Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates significant
hypoxemia and requires prompt intervention. The nurse should assess
respiratory status, position the client upright, administer oxygen as
prescribed, and continue monitoring. Mild peripheral edema and a
heart rate of 96/min are less immediately concerning.
,2.
A nurse is assessing a client who has chronic obstructive pulmonary
disease (COPD). Which finding is most consistent with this condition?
A. Bradycardia
B. Prolonged expiration
C. Absent breath sounds bilaterally
D. Sudden pleuritic chest pain
Answer: B. Prolonged expiration
Rationale: COPD causes airflow obstruction, making exhalation
particularly difficult. A prolonged expiratory phase and diminished
breath sounds are common findings. Sudden pleuritic chest pain is
more suggestive of conditions such as pulmonary embolism or
pneumothorax.
3.
A client with asthma develops wheezing and difficulty breathing after
exposure to an environmental trigger. Which medication should the
nurse expect to administer for rapid relief?
A. Fluticasone
B. Montelukast
,C. Albuterol
D. Salmeterol
Answer: C. Albuterol
Rationale: Albuterol is a short-acting beta2-adrenergic agonist used
as a rescue medication for acute bronchospasm. It rapidly relaxes
bronchial smooth muscle. Inhaled corticosteroids such as fluticasone
are controller medications rather than immediate rescue therapy.
4.
A nurse is caring for a client who has pneumonia. Which finding should
the nurse report to the provider immediately?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min
D. Fatigue with activity
Answer: C. Respiratory rate of 32/min
Rationale: A respiratory rate of 32/min indicates significant
tachypnea and can signal worsening respiratory distress or impaired
gas exchange. The other findings are common manifestations of
pneumonia but are not as immediately concerning.
, 5.
A nurse is monitoring a client who has a chest tube connected to a
water-seal drainage system. Which finding indicates that the system is
functioning appropriately?
A. Continuous vigorous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Absence of drainage for 24 hr
D. Chest tube disconnected from the drainage system
Answer: B. Tidaling in the water-seal chamber
Rationale: Tidaling, or fluctuation of the water level with respiration,
can indicate that the chest tube system is patent and responding to
changes in intrathoracic pressure. Continuous vigorous bubbling
usually suggests an air leak somewhere in the system.
6.
A client is admitted with suspected pulmonary embolism. Which finding
should the nurse expect?
COMPREHENSIVE Questions and Correct Answers
(Verified Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1.
A nurse is caring for a client who has acute heart failure and reports
increasing shortness of breath. Which assessment finding requires
immediate intervention?
A. 1+ bilateral ankle edema
B. Heart rate of 96/min
C. Oxygen saturation of 88% on room air
D. Blood pressure of 138/84 mm Hg
Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates significant
hypoxemia and requires prompt intervention. The nurse should assess
respiratory status, position the client upright, administer oxygen as
prescribed, and continue monitoring. Mild peripheral edema and a
heart rate of 96/min are less immediately concerning.
,2.
A nurse is assessing a client who has chronic obstructive pulmonary
disease (COPD). Which finding is most consistent with this condition?
A. Bradycardia
B. Prolonged expiration
C. Absent breath sounds bilaterally
D. Sudden pleuritic chest pain
Answer: B. Prolonged expiration
Rationale: COPD causes airflow obstruction, making exhalation
particularly difficult. A prolonged expiratory phase and diminished
breath sounds are common findings. Sudden pleuritic chest pain is
more suggestive of conditions such as pulmonary embolism or
pneumothorax.
3.
A client with asthma develops wheezing and difficulty breathing after
exposure to an environmental trigger. Which medication should the
nurse expect to administer for rapid relief?
A. Fluticasone
B. Montelukast
,C. Albuterol
D. Salmeterol
Answer: C. Albuterol
Rationale: Albuterol is a short-acting beta2-adrenergic agonist used
as a rescue medication for acute bronchospasm. It rapidly relaxes
bronchial smooth muscle. Inhaled corticosteroids such as fluticasone
are controller medications rather than immediate rescue therapy.
4.
A nurse is caring for a client who has pneumonia. Which finding should
the nurse report to the provider immediately?
A. Temperature of 38.1°C (100.6°F)
B. Productive cough
C. Respiratory rate of 32/min
D. Fatigue with activity
Answer: C. Respiratory rate of 32/min
Rationale: A respiratory rate of 32/min indicates significant
tachypnea and can signal worsening respiratory distress or impaired
gas exchange. The other findings are common manifestations of
pneumonia but are not as immediately concerning.
, 5.
A nurse is monitoring a client who has a chest tube connected to a
water-seal drainage system. Which finding indicates that the system is
functioning appropriately?
A. Continuous vigorous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Absence of drainage for 24 hr
D. Chest tube disconnected from the drainage system
Answer: B. Tidaling in the water-seal chamber
Rationale: Tidaling, or fluctuation of the water level with respiration,
can indicate that the chest tube system is patent and responding to
changes in intrathoracic pressure. Continuous vigorous bubbling
usually suggests an air leak somewhere in the system.
6.
A client is admitted with suspected pulmonary embolism. Which finding
should the nurse expect?
