ATI RN Medical Surgical Retake Latest 2026
Actual Exam | RN Med-Surg Proctored
Assessment II (Retake) with Complete Real
Exam Questions and Correct Verified
Answers / Already Graded A+
1. A nurse is assessing a client who has heart failure. Which finding should the
nurse recognize as an indication of worsening left-sided heart failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Enlarged liver
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure causes pulmonary congestion because the left
ventricle cannot effectively pump blood into systemic circulation. Crackles,
dyspnea, and pulmonary edema are common findings.
2. A nurse is caring for a client receiving a continuous IV infusion of heparin.
Which laboratory value should the nurse monitor to evaluate the therapeutic
effect?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: B. aPTT
,Rationale: The activated partial thromboplastin time (aPTT) is commonly
monitored to evaluate the therapeutic effect of unfractionated heparin.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen therapy. Which oxygen-delivery method is most appropriate when a
precise oxygen concentration is required?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen concentration and
is particularly useful for clients with COPD who require carefully titrated oxygen
therapy.
4. A nurse is caring for a client who has hypokalemia. Which finding should
the nurse expect?
A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, decreased bowel
motility, and cardiac dysrhythmias. Peaked T waves are associated with
hyperkalemia.
5. A nurse is assessing a client who has increased intracranial pressure. Which
finding requires immediate intervention?
A. Mild headache
B. Increasing level of consciousness
C. Unequal pupils
D. Occasional nausea
Answer: C. Unequal pupils
,Rationale: Unequal or newly dilated pupils can indicate worsening intracranial
pressure and possible brain herniation. This finding requires immediate evaluation
and intervention.
6. A client is receiving furosemide for fluid overload. Which laboratory value
is most important for the nurse to monitor?
A. Potassium
B. Calcium
C. Hemoglobin A1c
D. Amylase
Answer: A. Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss.
Hypokalemia increases the risk of muscle weakness and cardiac dysrhythmias.
7. A nurse is caring for a client who has diabetes mellitus and is experiencing
diaphoresis, tremors, and confusion. Which action should the nurse take first?
A. Administer the client's scheduled insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Administer a long-acting carbohydrate
Answer: B. Check the client's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic manifestations of
hypoglycemia. The nurse should promptly assess the blood glucose level and then
provide appropriate treatment.
8. A nurse is caring for a client who has a chest tube connected to a water-seal
drainage system. Which finding should the nurse report immediately?
A. Tidaling in the water-seal chamber
B. Mild discomfort at the insertion site
C. Continuous bubbling in the water-seal chamber
D. Drainage of 30 mL during the first hour
Answer: C. Continuous bubbling in the water-seal chamber
, Rationale: Continuous bubbling in the water-seal chamber can indicate an air leak
in the system. The nurse should assess the tubing and connections and notify the
appropriate provider if the source cannot be corrected.
9. A client with chronic kidney disease is prescribed dietary restrictions.
Which food should the nurse instruct the client to limit when hyperkalemia is
present?
A. Apples
B. White rice
C. Bananas
D. Bread
Answer: C. Bananas
Rationale: Bananas contain substantial potassium. Clients with chronic kidney
disease and hyperkalemia may require restriction of high-potassium foods.
10. A nurse is assessing a client who has a suspected pulmonary embolism.
Which finding is most concerning?
A. Sudden dyspnea
B. Productive cough for 2 weeks
C. Gradual weight gain
D. Bilateral ankle edema
Answer: A. Sudden dyspnea
Rationale: A pulmonary embolism can cause sudden dyspnea, pleuritic chest pain,
tachycardia, hypoxemia, and anxiety. Sudden respiratory symptoms require
prompt intervention.
11. A nurse is caring for a client who has cirrhosis and ascites. Which
assessment finding should the nurse expect?
A. Increased abdominal girth
B. Decreased abdominal pressure
C. Severe hypoglycemia in every case
D. Increased urine output
Answer: A. Increased abdominal girth
Actual Exam | RN Med-Surg Proctored
Assessment II (Retake) with Complete Real
Exam Questions and Correct Verified
Answers / Already Graded A+
1. A nurse is assessing a client who has heart failure. Which finding should the
nurse recognize as an indication of worsening left-sided heart failure?
A. Dependent peripheral edema
B. Jugular venous distention
C. Crackles in the lung bases
D. Enlarged liver
Answer: C. Crackles in the lung bases
Rationale: Left-sided heart failure causes pulmonary congestion because the left
ventricle cannot effectively pump blood into systemic circulation. Crackles,
dyspnea, and pulmonary edema are common findings.
2. A nurse is caring for a client receiving a continuous IV infusion of heparin.
Which laboratory value should the nurse monitor to evaluate the therapeutic
effect?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: B. aPTT
,Rationale: The activated partial thromboplastin time (aPTT) is commonly
monitored to evaluate the therapeutic effect of unfractionated heparin.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen therapy. Which oxygen-delivery method is most appropriate when a
precise oxygen concentration is required?
A. Nonrebreather mask
B. Venturi mask
C. Simple face mask
D. Partial-rebreather mask
Answer: B. Venturi mask
Rationale: A Venturi mask delivers a precise, controlled oxygen concentration and
is particularly useful for clients with COPD who require carefully titrated oxygen
therapy.
4. A nurse is caring for a client who has hypokalemia. Which finding should
the nurse expect?
A. Muscle weakness
B. Hyperactive reflexes
C. Peaked T waves
D. Severe hypertension
Answer: A. Muscle weakness
Rationale: Hypokalemia can cause muscle weakness, fatigue, decreased bowel
motility, and cardiac dysrhythmias. Peaked T waves are associated with
hyperkalemia.
5. A nurse is assessing a client who has increased intracranial pressure. Which
finding requires immediate intervention?
A. Mild headache
B. Increasing level of consciousness
C. Unequal pupils
D. Occasional nausea
Answer: C. Unequal pupils
,Rationale: Unequal or newly dilated pupils can indicate worsening intracranial
pressure and possible brain herniation. This finding requires immediate evaluation
and intervention.
6. A client is receiving furosemide for fluid overload. Which laboratory value
is most important for the nurse to monitor?
A. Potassium
B. Calcium
C. Hemoglobin A1c
D. Amylase
Answer: A. Potassium
Rationale: Furosemide is a loop diuretic that can cause significant potassium loss.
Hypokalemia increases the risk of muscle weakness and cardiac dysrhythmias.
7. A nurse is caring for a client who has diabetes mellitus and is experiencing
diaphoresis, tremors, and confusion. Which action should the nurse take first?
A. Administer the client's scheduled insulin
B. Check the client's blood glucose level
C. Encourage the client to ambulate
D. Administer a long-acting carbohydrate
Answer: B. Check the client's blood glucose level
Rationale: Diaphoresis, tremors, and confusion are classic manifestations of
hypoglycemia. The nurse should promptly assess the blood glucose level and then
provide appropriate treatment.
8. A nurse is caring for a client who has a chest tube connected to a water-seal
drainage system. Which finding should the nurse report immediately?
A. Tidaling in the water-seal chamber
B. Mild discomfort at the insertion site
C. Continuous bubbling in the water-seal chamber
D. Drainage of 30 mL during the first hour
Answer: C. Continuous bubbling in the water-seal chamber
, Rationale: Continuous bubbling in the water-seal chamber can indicate an air leak
in the system. The nurse should assess the tubing and connections and notify the
appropriate provider if the source cannot be corrected.
9. A client with chronic kidney disease is prescribed dietary restrictions.
Which food should the nurse instruct the client to limit when hyperkalemia is
present?
A. Apples
B. White rice
C. Bananas
D. Bread
Answer: C. Bananas
Rationale: Bananas contain substantial potassium. Clients with chronic kidney
disease and hyperkalemia may require restriction of high-potassium foods.
10. A nurse is assessing a client who has a suspected pulmonary embolism.
Which finding is most concerning?
A. Sudden dyspnea
B. Productive cough for 2 weeks
C. Gradual weight gain
D. Bilateral ankle edema
Answer: A. Sudden dyspnea
Rationale: A pulmonary embolism can cause sudden dyspnea, pleuritic chest pain,
tachycardia, hypoxemia, and anxiety. Sudden respiratory symptoms require
prompt intervention.
11. A nurse is caring for a client who has cirrhosis and ascites. Which
assessment finding should the nurse expect?
A. Increased abdominal girth
B. Decreased abdominal pressure
C. Severe hypoglycemia in every case
D. Increased urine output
Answer: A. Increased abdominal girth
