ATI RN MEDICAL SURGICAL
QUESTIONS AND ANSWERS
2025 100% CORRECT GRADE
A+
1. A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs: - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to assess the
client's vital signs. A client who has portal HTN can develop esophageal varices, which are
fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs
provides information about the client's condition that can contribute to decision making.
,2. 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?
- Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
- pH 7.28 (7.35 to 7.45)
- Glucose 272 mg/dL (74 to 106 mg/dL)
- HCO3- 14 mEq/L (21 to 28 mEq/L): - Glucose 272 mg/dL (74 to 106 mg/dL)
RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the client's
status.
3. 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?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints: - Alternate 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.
,4. A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities: - Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are
manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the
client's ability to breath, place the client in an upright position, and notify the provider. The
provider might prescribe a diuretic to alleviate the fluid overload.
5. A nurse in the emergency department is assessing a client who has a detached retina.
Which of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks." - "I seem to
have more problems seeing different colors.": - "It's like a curtain closed over my eye."
RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can
occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled over part of the visual field.
, 6. A nurse is teaching a client who has a family history of colorectal cancer.
To help mitigate this risk, which of the following dietary alterations should the nurse
recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat: - Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet that
is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as
cabbage, cauliflower, and broccoli, are high in fiber.
7. A nurse is caring for a client who has a leg cast and is returning to demonstrate on the
proper use of crutches while climbing stairs. Identify the sequence the client should follow
when demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair: - Places body weight on the crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
QUESTIONS AND ANSWERS
2025 100% CORRECT GRADE
A+
1. A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed
with food after a meal. Which of the following actions should the nurse take first?
- Check laboratory values for recent hemoglobin and hematocrit levels
- Establish a peripheral IV line for possible transfusion
- Call the laboratory to obtain a stat platelet count
- Obtain vital signs: - Obtain vital signs
RATIONALE: The first action the nurse should take using the nursing process is to assess the
client's vital signs. A client who has portal HTN can develop esophageal varices, which are
fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs
provides information about the client's condition that can contribute to decision making.
,2. 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?
- Potassium 3.2 mEq/L (3.5 to 5 mEq/L)
- pH 7.28 (7.35 to 7.45)
- Glucose 272 mg/dL (74 to 106 mg/dL)
- HCO3- 14 mEq/L (21 to 28 mEq/L): - Glucose 272 mg/dL (74 to 106 mg/dL)
RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the client's
status.
3. 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?
- Increase intake of foods containing calcium
- Alternate application of heat and cold to the affected joints
- Keep the affected extremities elevated
- Limit movement of the affected joints: - Alternate 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.
,4. A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
- Administer an antihistamine
- Slow the infusion rate
- Give the client a corticosteroid
- Elevate the client's lower extremities: - Slow the infusion rate
RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are
manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the
client's ability to breath, place the client in an upright position, and notify the provider. The
provider might prescribe a diuretic to alleviate the fluid overload.
5. A nurse in the emergency department is assessing a client who has a detached retina.
Which of the following should the nurse expect the client to report?
- "It's like a curtain closed over my eye."
- "This sharp pain in my eye started 2 hours ago."
- "I've been having more and more difficulty seeing over the last few weeks." - "I seem to
have more problems seeing different colors.": - "It's like a curtain closed over my eye."
RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can
occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal
detachment typically report the sensation of a curtain being pulled over part of the visual field.
, 6. A nurse is teaching a client who has a family history of colorectal cancer.
To help mitigate this risk, which of the following dietary alterations should the nurse
recommend?
- Add full-fat yogurt to the diet
- Add cabbage to the diet
- Replace butter with coconut oil
- Replace shellfish with red meat: - Add cabbage to the diet
RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet that
is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as
cabbage, cauliflower, and broccoli, are high in fiber.
7. A nurse is caring for a client who has a leg cast and is returning to demonstrate on the
proper use of crutches while climbing stairs. Identify the sequence the client should follow
when demonstrating crutch use.
- Brings the crutches and the affected leg up to the stair
- Places body weight on the crutches
- Shifts weight from the crutches to the unaffected leg
- Advances the unaffected leg onto the stair: - Places body weight on the crutches
- Advances the unaffected leg onto the stair
- Shifts weight from the crutches to the unaffected leg
