ATI MEDSURG RETAKE EXAM GUIDE
LATEST (2025)
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the
following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
, k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
, client swho shas sa schest stube sto sclamp sthe stube sand sprevent sair sfrom
sentering sthe sclient's schest sif sthere sis san sinterruption sin sthe ssealed sdrainage
ssystem.
h. Communication sboard: sThe snurse sshould sensure sa scommunication sboard sis sat
sthesbedside sof sa sclient swho shas saphasia sto sassist sthe sclient swith
scommunicating.
5. A snurse sis scaring sfor sa sclient swho sis shaving sa sseizure. sWhich sof sthe sfollowing sintervention sis sthe snurse’s
spriority?
a. Loosen sthe sclothing saround sthe sclient’s sneck
b. Check sthe sclient’s spupillary sresponse
c. Turn sthe sclient sto sthe sside.
d. Move sfurniture saway sfrom sthe sclient
i. Loosen sthe sclothing saround sthe sclient's sneck: sThe snurse sshould
sloosen sanysrestrictive sclothing sthe sclient sis swearing sto sprevent sinjury
sto sthe sclient. sHowever, sanother saction sis sthe spriority.
ii. Check sthe sclient's spupillary sresponse: sThe snurse sshould sperform
sneurologic schecks safter sthe sseizure sto smonitor sthe sclient's srecovery.
sHowever, sanothersaction sis sthe spriority.
iii. Turn sthe sclient sto sthe sside.: sThe sgreatest srisk sto sthis sclient sis shypoxia
sfrom san simpaired sairway. sTherefore, sthe spriority sintervention sthe snurse
sshould stake sis sto splace sthe sclient sin sa sside-lying sposition sto sprevent
saspiration.
iv. Move sfurniture saway sfrom sthe sclient.: sAThe snurse sshould smove sfurniture
saway sfrom s the s client s to s prevent s self-injury. s However, s another s action s is
s the s priority.
6. A snurse sis sproviding steaching sto saclient swho shas shypothyroidism sand sis sreceiving slevothyroxine. sThe snurse
sshouldsinstruct sthe sclient sthat swhich sof sthe sfollowing ssupplements scan sinterfere swith sthe seffectiveness
sof sthe smedication?
a. Ginkgo sbiloba
b. Glucosamine
c. Calcium
d. Vitamin sC
i.
Ginkgo sbiloba
ii. Ginkgo s biloba s reduces s the s pain s associated s with s peripheral s vascular
s disease sby spromoting svasodilation. sIt scan sinteract swith smedications sthat
shave santicoagulant sproperties, sbut sit sis snot sknown sto sinterfere swith sthe
sabsorptionsof slevothyroxine.
iii. Glucosamine: sGlucosamine streats sosteoarthritis sby sdecreasing
sinflammationsand sstimulating sthe sbody's s production sof ssynovial sfluid sand
scartilage. sIt scan sinteract swith smedications sthat shave santiplatelet sor
, santicoagulant sproperties, sbut sit sis snot sknown sto sinterfere swith sthe
sabsorption sof slevothyroxine.
iv. Calcium:NSWER
v. Calcium slimits sthe sdevelopment sof sosteoporosis sin sclients swho sare
spostmenopausal sand sworks sas san santacid. sCalcium ssupplements scan
sinterfere
with sthe smetabolism sof sa snumber sof smedications, sincluding slevothyroxine.
sThesnurse sshould sinstruct sthe sclient sto savoid staking scalcium swithin s4 shr sof
slevothyroxine sadministration.
vi. Vitamin sC: sVitamin sC spromotes swound shealing. sIt scan scause sa sfalse
snegativesin sfecal soccult sblood stests, sbut sit sis snot sknown sto sinterfere swith
sthe sabsorption
of s levothyroxine.
7. A snurse sis splanning sto sirrigate sand sdress sa sclean, sgranulation swound sfor sa sclient swho shas sa spressure
sinjury. sWhichsof sthe sfollowing sactions sshould sthe snurse stake?
a. Apply sa swet-to-dry sgauze sdressing
b. Irrigate swith shydrogen speroxide ssolution
c. Use sa s30-ml ssyringe
d. Attach sa s24-gauge sangiocatheter sto sthe ssyringe.
s 8.
a. Apply sa s wet-to-dry s gauze s dressing.: s The s nurse s should s not s apply s wet-to-dry
s dressings sto s clean, s granulating s wounds s as s they s interrupt s viable, s healing s tissues
s when s they s aresremoved. s Appropriate s dressings s for s a s wound s that s is s developing
s granulation s tissue sinclude sa shydrocolloid sdressing sand sa stransparent sfilm
sdressing.
b. Irrigate swith shydrogen speroxide ssolution: sthe s nurse s should s use s hydrogen
s peroxide s to sclean s contaminated s surfaces. s Hydrogen s peroxide s should s not s be
s used s on s a s pressure sinjury s wound s because s it s destroys s newly s granulated s tissue.
s Instead, s the s nurse s shouldsuse s solutions s specifically s designed s as s wound
s cleansers s or s 0.9% s sodium s chloride sirrigation sto sirrigate sthe swound.
c. Use sa s30-mL ssyringe: sNSWERThe snurse sshould suse sa s30-mL sto s60-mL
ssyringe swithsan s 18- s or s 19-gauge s catheter s to s deliver s the s ideal s pressure s of s 8
s pounds s per s square sinch s(psi) swhen sirrigating sa swound. sTo smaintain shealthy
sgranulation stissue, sthe swound sirrigation sshould sbe sdelivered sat sbetween s4 sand
s15 spsi.
LATEST (2025)
1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of
the following findings indicates that the client is experiencing increased ICP?
a. Flat jugular veins
b. GCS score of 15
c. Sleepiness exhibited by the client
d. Widening pulse pressure
e. Decerebrate posturing
f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15
indicates neurological functioning within the expected reference range for eye opening, motor,
and verbal response.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the
following prescribed medications should the nurse instruct the clients to withhold for 48hr prior to
cardioversion?
a. Enoxaparin
b. Metformin
c. Diazepam
d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent
blood clots that can be released into the client's circulatory system after
cardioversion. This medication should not be withheld.
f. Metformin
g. Metformin might be withheld for a client scheduled for cardiac catheterization or
other procedures involving contrast dye in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
h. Diazepam
i. Sedatives are generally administered to clients prior to cardioversion to reduce
anxiety and minimize the discomfort associated with the procedure. This medication
should not be withheld.
j. Digoxin: ANSWER
, k. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These
medications can increase ventricular irritability and put the client at risk for
ventricular fibrillation after the synchronized countershock of cardioversion.
3. A nurse is assessing a client who has acute cholecystitis. which of the following findings is the nurse’s priority?
a. Anorexia
b. Abdominal pain radiating to the right shoulder
c. Tachycardia
d. Rebound abdominal tenderness
i.
Anorexia
ii. Anorexia is nonurgent because it is an expected finding for a client who has
acute cholecystitis. Therefore, there is another finding that is the nurse's
priority.
iii. Abdominal pain radiating to the right shoulder
iv. MY ANSWER
v. Abdominal pain radiating to the right shoulder is nonurgent because it is an
expected finding for a client who has acute cholecystitis. Therefore, there is
another finding that is the nurse's priority.
vi. Tachycardia
vii. When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is tachycardia. Tachycardia is a
manifestation of biliary colic, which can lead to shock. The nurse should
position the head of the client's bed flat and report this finding immediately
to the provider.
viii. Rebound abdominal tenderness
ix. Rebound abdominal tenderness is nonurgent because it is an expected
finding for a client who has acute cholecystitis. Therefore, there is another
finding that is the nurse's priority.
4. A nurse is preparing to admit a client who has dysphagia. The nurse should plant to place which of the following
items at the client’s bedside?
a. Suction machine
b. Wire cutters
c. Padded clamp
d. Communication board
e. Suction machine: ANSWERThe nurse should ensure that a suction machine is at the
bedside of a client who has dysphagia to clear the client's airway as needed and
reduce the risk for aspiration.
f. Wire cutters: The nurse should ensure wire cutters are at the bedside of a client
who has an inner maxillary fixation to cut the wires in case the client vomits. This
enables the client to clear their airway and reduce the risk for aspiration.
g. Padded clamp: The nurse should ensure a padded clamp is at the bedside of a
, client swho shas sa schest stube sto sclamp sthe stube sand sprevent sair sfrom
sentering sthe sclient's schest sif sthere sis san sinterruption sin sthe ssealed sdrainage
ssystem.
h. Communication sboard: sThe snurse sshould sensure sa scommunication sboard sis sat
sthesbedside sof sa sclient swho shas saphasia sto sassist sthe sclient swith
scommunicating.
5. A snurse sis scaring sfor sa sclient swho sis shaving sa sseizure. sWhich sof sthe sfollowing sintervention sis sthe snurse’s
spriority?
a. Loosen sthe sclothing saround sthe sclient’s sneck
b. Check sthe sclient’s spupillary sresponse
c. Turn sthe sclient sto sthe sside.
d. Move sfurniture saway sfrom sthe sclient
i. Loosen sthe sclothing saround sthe sclient's sneck: sThe snurse sshould
sloosen sanysrestrictive sclothing sthe sclient sis swearing sto sprevent sinjury
sto sthe sclient. sHowever, sanother saction sis sthe spriority.
ii. Check sthe sclient's spupillary sresponse: sThe snurse sshould sperform
sneurologic schecks safter sthe sseizure sto smonitor sthe sclient's srecovery.
sHowever, sanothersaction sis sthe spriority.
iii. Turn sthe sclient sto sthe sside.: sThe sgreatest srisk sto sthis sclient sis shypoxia
sfrom san simpaired sairway. sTherefore, sthe spriority sintervention sthe snurse
sshould stake sis sto splace sthe sclient sin sa sside-lying sposition sto sprevent
saspiration.
iv. Move sfurniture saway sfrom sthe sclient.: sAThe snurse sshould smove sfurniture
saway sfrom s the s client s to s prevent s self-injury. s However, s another s action s is
s the s priority.
6. A snurse sis sproviding steaching sto saclient swho shas shypothyroidism sand sis sreceiving slevothyroxine. sThe snurse
sshouldsinstruct sthe sclient sthat swhich sof sthe sfollowing ssupplements scan sinterfere swith sthe seffectiveness
sof sthe smedication?
a. Ginkgo sbiloba
b. Glucosamine
c. Calcium
d. Vitamin sC
i.
Ginkgo sbiloba
ii. Ginkgo s biloba s reduces s the s pain s associated s with s peripheral s vascular
s disease sby spromoting svasodilation. sIt scan sinteract swith smedications sthat
shave santicoagulant sproperties, sbut sit sis snot sknown sto sinterfere swith sthe
sabsorptionsof slevothyroxine.
iii. Glucosamine: sGlucosamine streats sosteoarthritis sby sdecreasing
sinflammationsand sstimulating sthe sbody's s production sof ssynovial sfluid sand
scartilage. sIt scan sinteract swith smedications sthat shave santiplatelet sor
, santicoagulant sproperties, sbut sit sis snot sknown sto sinterfere swith sthe
sabsorption sof slevothyroxine.
iv. Calcium:NSWER
v. Calcium slimits sthe sdevelopment sof sosteoporosis sin sclients swho sare
spostmenopausal sand sworks sas san santacid. sCalcium ssupplements scan
sinterfere
with sthe smetabolism sof sa snumber sof smedications, sincluding slevothyroxine.
sThesnurse sshould sinstruct sthe sclient sto savoid staking scalcium swithin s4 shr sof
slevothyroxine sadministration.
vi. Vitamin sC: sVitamin sC spromotes swound shealing. sIt scan scause sa sfalse
snegativesin sfecal soccult sblood stests, sbut sit sis snot sknown sto sinterfere swith
sthe sabsorption
of s levothyroxine.
7. A snurse sis splanning sto sirrigate sand sdress sa sclean, sgranulation swound sfor sa sclient swho shas sa spressure
sinjury. sWhichsof sthe sfollowing sactions sshould sthe snurse stake?
a. Apply sa swet-to-dry sgauze sdressing
b. Irrigate swith shydrogen speroxide ssolution
c. Use sa s30-ml ssyringe
d. Attach sa s24-gauge sangiocatheter sto sthe ssyringe.
s 8.
a. Apply sa s wet-to-dry s gauze s dressing.: s The s nurse s should s not s apply s wet-to-dry
s dressings sto s clean, s granulating s wounds s as s they s interrupt s viable, s healing s tissues
s when s they s aresremoved. s Appropriate s dressings s for s a s wound s that s is s developing
s granulation s tissue sinclude sa shydrocolloid sdressing sand sa stransparent sfilm
sdressing.
b. Irrigate swith shydrogen speroxide ssolution: sthe s nurse s should s use s hydrogen
s peroxide s to sclean s contaminated s surfaces. s Hydrogen s peroxide s should s not s be
s used s on s a s pressure sinjury s wound s because s it s destroys s newly s granulated s tissue.
s Instead, s the s nurse s shouldsuse s solutions s specifically s designed s as s wound
s cleansers s or s 0.9% s sodium s chloride sirrigation sto sirrigate sthe swound.
c. Use sa s30-mL ssyringe: sNSWERThe snurse sshould suse sa s30-mL sto s60-mL
ssyringe swithsan s 18- s or s 19-gauge s catheter s to s deliver s the s ideal s pressure s of s 8
s pounds s per s square sinch s(psi) swhen sirrigating sa swound. sTo smaintain shealthy
sgranulation stissue, sthe swound sirrigation sshould sbe sdelivered sat sbetween s4 sand
s15 spsi.
