ATI RN ADULT MEDICAL-SURGICAL NURSING
ATI RN ADULT MEDICAL-
SURGICAL NURSING
QUESTIONS AND DETAILED
ANSWERS 2025
A nurse is caring for a client who has homonymous hemianopsia as result of a
stroke. To reduce the risk of falls when ambulating the nurse should provide which
of the following instructions to the client? - ANS >>"Scan the environment by
turning your head from side to side."
Rationale: Homonymous hemianopsia is the loss of the same visual field in both
eyes. Turning their head from side to side helps enlarge a client's visual field. This
technique is also useful for the client during mealtimes.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which
of the following results should the nurse expect? - ANS >>PaCO2 56mmHg
Rationale: A client who has COPD retains PaCO2 due to the weakening and the
collapse of the alveolar sacs, which decreases the area in the lungs for gas
exchange and causes the PaCO2 to increase above the expected reference range.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - ANS >>Change position every hour
1
,ATI RN ADULT MEDICAL-SURGICAL NURSING
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the hips
when in a lateral position to no more than 30°. This positioning prevents direct
pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - ANS
>>Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is restlessness, which
can be an indication the client is experiencing disequilibrium syndrome.
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the
client's blood and can lead to dysrhythmias or seizures. Other manifestations
include nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ANS >>Scan the bladder with a portable
ultrasound.
Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders presents
the greatest risk to this group of clients? - ANS >>Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
2
, ATI RN ADULT MEDICAL-SURGICAL NURSING
A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client's condition is improving? - ANS
>>Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min.
ago. Which of the following findings should the nurse report to the provider
immediately? - ANS >>Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is stridor. Stridor can indicate a narrowing
airway or possible obstruction caused by edema or laryngeal spasms. The nurse
should report the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago.
Which of the following findings should the nurse report to the provider? - ANS
>>The client reports back pain
Rationale: The nurse should notify the provider if the client reports back pain,
which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANS >>Airborne
Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such
as tuberculosis, measles, varicella, and disseminated varicella zoster.
3
ATI RN ADULT MEDICAL-
SURGICAL NURSING
QUESTIONS AND DETAILED
ANSWERS 2025
A nurse is caring for a client who has homonymous hemianopsia as result of a
stroke. To reduce the risk of falls when ambulating the nurse should provide which
of the following instructions to the client? - ANS >>"Scan the environment by
turning your head from side to side."
Rationale: Homonymous hemianopsia is the loss of the same visual field in both
eyes. Turning their head from side to side helps enlarge a client's visual field. This
technique is also useful for the client during mealtimes.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which
of the following results should the nurse expect? - ANS >>PaCO2 56mmHg
Rationale: A client who has COPD retains PaCO2 due to the weakening and the
collapse of the alveolar sacs, which decreases the area in the lungs for gas
exchange and causes the PaCO2 to increase above the expected reference range.
A home health nurse is providing teaching to a client who has a stage 1 pressure
injury on the greater trochanter of his left hip. Which of the following instructions
should the nurse include in the teaching? - ANS >>Change position every hour
1
,ATI RN ADULT MEDICAL-SURGICAL NURSING
Rationale: Changing position every 1 to 2 hr decreases pressure on bony
prominences. The nurse should also instruct the client to limit the angle of the hips
when in a lateral position to no more than 30°. This positioning prevents direct
pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of
the following findings is the nurse's priority to report to the provider? - ANS
>>Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is restlessness, which
can be an indication the client is experiencing disequilibrium syndrome.
Disequilibrium syndrome is caused by the rapid removal of electrolytes from the
client's blood and can lead to dysrhythmias or seizures. Other manifestations
include nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip
arthroplasty. The client is unable to void on the bedpan. Which of the following
actions should the nurse take first? - ANS >>Scan the bladder with a portable
ultrasound.
Rationale: The first action the nurse should take using the nursing process is to
assess the client. Scanning the bladder with a portable ultrasound device will
determine the amount of urine in the bladder
A nurse is planning a health promotional presentation for a group of African
American clients at a community center. Which of the following disorders presents
the greatest risk to this group of clients? - ANS >>Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse
should determine that the disorder with the greatest risk for this group of clients is
hypertension. The prevalence of hypertension is highest among African American
clients, followed by Caucasian clients, and then Hispanic clients.
2
, ATI RN ADULT MEDICAL-SURGICAL NURSING
A nurse is caring for a client who has DKA. Which of the following findings
should indicate to the nurse that the client's condition is improving? - ANS
>>Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the
client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min.
ago. Which of the following findings should the nurse report to the provider
immediately? - ANS >>Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is stridor. Stridor can indicate a narrowing
airway or possible obstruction caused by edema or laryngeal spasms. The nurse
should report the finding immediately and implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago.
Which of the following findings should the nurse report to the provider? - ANS
>>The client reports back pain
Rationale: The nurse should notify the provider if the client reports back pain,
which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of
transmission precautions should the nurse initiate? - ANS >>Airborne
Rationale: Airborne precautions are required for clients who have infections due to
micro-organisms that can remain suspended in air for lengthy periods of time, such
as tuberculosis, measles, varicella, and disseminated varicella zoster.
3
