ATI RN ADULT MEDICAL-SURGICAL NURSING 2024-2025
/RN ADULT MEDICAL SURGICAL NURSING ACTUAL EXAM
TEST BANK 150 QUESTIONS AND CORRECT DETAILED
ANSWERS
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
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 at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent
airway, which of the following nursing interventions is the priority? - ANS -Applying oxygen via face mask
Rationale: Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse
should use a high-flow non rebreather mask to deliver oxygen at 90% to 100%.
\A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During
the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the
following actions is the nurse's priority? - ANS -Check the client's neurologic status.
Rationale: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse
should first check the neurologic status of the client.
\A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic
transfusion reaction? - ANS -Low back pain and apprehension
Rationale: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic
inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
,\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.
\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 assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should
indicate to the nurse the client is experiencing hypoxia? - ANS -The client's heart rate increases.
Rationale: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should
discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to
take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.
\A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological
interventions should the nurse suggest to the client to reduce pain? - ANS -Alternate the application of heat and cold to
the affected joints.
Rationale: The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and
pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.
\A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just
undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of
advanced cancer? - ANS -Dyspnea
Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing
and improve comfort.
\A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? - ANS
-Low urine specific gravity
, Rationale: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005.
Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the
kidneys' responsiveness to the hormone.
\A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse
expect? - ANS -Hair loss on the lower legs
Rationale: The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a
result of impaired arterial circulation affecting follicular growth.
\A nurse is assessing a client who is at risk for the development of pernicious anemia from peptic ulcer disease. Which of
the following images depicts a condition caused by pernicious anemia? - ANS -Glossitis
Rationale: This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a
manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.
\A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's
priority? - ANS -Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority
finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or
thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider
because it can lead to seizures and coma.
\A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes
clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the
nurse take? - ANS -Irrigate the indwelling urinary catheter.
Rationale: The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.
\A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? - ANS
-Distended neck veins
Rationale: The nurse should identify distended neck and hand veins as indicators of fluid volume overload.
\A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which f the following findings should
the nurse identify as a manifestation of this condition? - ANS -Pain that increases with passive movement
Rationale: The nurse should identify that a client who has compartment syndrome experiences pain that increases with
passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease
in the muscle compartment size due to a cast that is too tight.
/RN ADULT MEDICAL SURGICAL NURSING ACTUAL EXAM
TEST BANK 150 QUESTIONS AND CORRECT DETAILED
ANSWERS
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
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 at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent
airway, which of the following nursing interventions is the priority? - ANS -Applying oxygen via face mask
Rationale: Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse
should use a high-flow non rebreather mask to deliver oxygen at 90% to 100%.
\A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During
the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the
following actions is the nurse's priority? - ANS -Check the client's neurologic status.
Rationale: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse
should first check the neurologic status of the client.
\A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic
transfusion reaction? - ANS -Low back pain and apprehension
Rationale: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic
inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
,\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.
\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 assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should
indicate to the nurse the client is experiencing hypoxia? - ANS -The client's heart rate increases.
Rationale: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should
discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to
take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.
\A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological
interventions should the nurse suggest to the client to reduce pain? - ANS -Alternate the application of heat and cold to
the affected joints.
Rationale: The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and
pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.
\A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just
undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of
advanced cancer? - ANS -Dyspnea
Rationale: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing
and improve comfort.
\A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? - ANS
-Low urine specific gravity
, Rationale: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005.
Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the
kidneys' responsiveness to the hormone.
\A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse
expect? - ANS -Hair loss on the lower legs
Rationale: The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a
result of impaired arterial circulation affecting follicular growth.
\A nurse is assessing a client who is at risk for the development of pernicious anemia from peptic ulcer disease. Which of
the following images depicts a condition caused by pernicious anemia? - ANS -Glossitis
Rationale: This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a
manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.
\A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's
priority? - ANS -Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority
finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or
thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider
because it can lead to seizures and coma.
\A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes
clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the
nurse take? - ANS -Irrigate the indwelling urinary catheter.
Rationale: The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.
\A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? - ANS
-Distended neck veins
Rationale: The nurse should identify distended neck and hand veins as indicators of fluid volume overload.
\A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which f the following findings should
the nurse identify as a manifestation of this condition? - ANS -Pain that increases with passive movement
Rationale: The nurse should identify that a client who has compartment syndrome experiences pain that increases with
passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease
in the muscle compartment size due to a cast that is too tight.
