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 fwho fhas fa fchest ftube fto fclamp fthe ftube fand fprevent fair ffrom
fentering fthe fclient's fchest fif fthere fis fan finterruption fin fthe fsealed fdrainage
fsystem.
h. Communication fboard: fThe fnurse fshould fensure fa fcommunication fboard fis fat
fthefbedside fof fa fclient fwho fhas faphasia fto fassist fthe fclient fwith
fcommunicating.
5. A fnurse fis fcaring ffor fa fclient fwho fis fhaving fa fseizure. fWhich fof fthe ffollowing fintervention fis fthe fnurse’s
fpriority?
a. Loosen fthe fclothing faround fthe fclient’s fneck
b. Check fthe fclient’s fpupillary fresponse
c. Turn fthe fclient fto fthe fside.
d. Move ffurniture faway ffrom fthe fclient
i. Loosen fthe fclothing faround fthe fclient's fneck: fThe fnurse fshould floosen
fanyfrestrictive fclothing fthe fclient fis fwearing fto fprevent finjury fto fthe
fclient. fHowever, fanother faction fis fthe fpriority.
ii. Check fthe fclient's fpupillary fresponse: fThe fnurse fshould fperform
fneurologic fchecks fafter fthe fseizure fto fmonitor fthe fclient's frecovery.
fHowever, fanotherfaction fis fthe fpriority.
iii. Turn fthe fclient fto fthe fside.: fThe fgreatest frisk fto fthis fclient fis fhypoxia
ffrom fan fimpaired fairway. fTherefore, fthe fpriority fintervention fthe fnurse
fshould ftake fis fto fplace fthe fclient fin fa fside-lying fposition fto fprevent
faspiration.
iv. Move ffurniture faway ffrom fthe fclient.: fAThe fnurse fshould fmove ffurniture
faway ffrom f the f client f to f prevent f self-injury. f However, f another f action f is
f the f priority.
6. A fnurse fis fproviding fteaching fto faclient fwho fhas fhypothyroidism fand fis freceiving flevothyroxine. fThe fnurse
fshouldfinstruct fthe fclient fthat fwhich fof fthe ffollowing fsupplements fcan finterfere fwith fthe feffectiveness fof
fthe fmedication?
a. Ginkgo fbiloba
b. Glucosamine
c. Calcium
d. Vitamin fC
i.
Ginkgo fbiloba
ii. Ginkgo f biloba f reduces f the f pain f associated f with f peripheral f vascular
f disease fby fpromoting fvasodilation. fIt fcan finteract fwith fmedications fthat
fhave fanticoagulant fproperties, fbut fit fis fnot fknown fto finterfere fwith fthe
fabsorptionfof flevothyroxine.
iii. Glucosamine: fGlucosamine ftreats fosteoarthritis fby fdecreasing
finflammationfand fstimulating fthe fbody's fproduction fof fsynovial ffluid fand
fcartilage. fIt fcan finteract fwith fmedications fthat fhave fantiplatelet for
, fanticoagulant fproperties, fbut fit fis fnot fknown fto finterfere fwith fthe
fabsorption fof flevothyroxine.
iv. Calcium:NSWER
v. Calcium flimits fthe fdevelopment fof fosteoporosis fin fclients fwho fare
fpostmenopausal fand fworks fas fan fantacid. fCalcium fsupplements fcan
finterfere
with fthe fmetabolism fof fa fnumber fof fmedications, fincluding flevothyroxine.
fThefnurse fshould finstruct fthe fclient fto favoid ftaking fcalcium fwithin f4 fhr fof
flevothyroxine fadministration.
vi. Vitamin fC: fVitamin fC fpromotes fwound fhealing. fIt fcan fcause fa ffalse
fnegativefin ffecal foccult fblood ftests, fbut fit fis fnot fknown fto finterfere fwith
fthe fabsorption
of f levothyroxine.
7. A fnurse fis fplanning fto firrigate fand fdress fa fclean, fgranulation fwound ffor fa fclient fwho fhas fa fpressure finjury.
fWhichfof fthe ffollowing factions fshould fthe fnurse ftake?
a. Apply fa fwet-to-dry fgauze fdressing
b. Irrigate fwith fhydrogen fperoxide fsolution
c. Use fa f30-ml fsyringe
d. Attach fa f24-gauge fangiocatheter fto fthe fsyringe.
f 8.
a. Apply f a f wet-to-dry f gauze f dressing.: f The f nurse f should f not f apply f wet-to-dry
f dressings fto f clean, f granulating f wounds f as f they f interrupt f viable, f healing f tissues
f when f they f arefremoved. f Appropriate f dressings f for f a f wound f that f is f developing
f granulation f tissue finclude fa fhydrocolloid fdressing fand fa ftransparent ffilm
fdressing.
b. Irrigate fwith f hydrogen fperoxide fsolution: fthe fnurse fshould fuse fhydrogen fperoxide
f to fclean f contaminated f surfaces. f Hydrogen f peroxide f should f not f be f used f on f a
f pressure finjury f wound f because f it f destroys f newly f granulated f tissue. f Instead,
f the f nurse f shouldfuse f solutions f specifically f designed f as f wound f cleansers f or f 0.9%
f sodium f chloride firrigation fto firrigate fthe fwound.
c. Use fa f30-mL fsyringe: fNSWERThe fnurse fshould fuse fa f30-mL fto f60-mL fsyringe
fwithfan f 18- f or f 19-gauge f catheter f to f deliver f the f ideal f pressure f of f 8 f pounds
f per f square finch f(psi) fwhen firrigating fa fwound. fTo fmaintain fhealthy
fgranulation ftissue, fthe fwound firrigation fshould fbe fdelivered fat fbetween f4 fand
f15 fpsi.
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 fwho fhas fa fchest ftube fto fclamp fthe ftube fand fprevent fair ffrom
fentering fthe fclient's fchest fif fthere fis fan finterruption fin fthe fsealed fdrainage
fsystem.
h. Communication fboard: fThe fnurse fshould fensure fa fcommunication fboard fis fat
fthefbedside fof fa fclient fwho fhas faphasia fto fassist fthe fclient fwith
fcommunicating.
5. A fnurse fis fcaring ffor fa fclient fwho fis fhaving fa fseizure. fWhich fof fthe ffollowing fintervention fis fthe fnurse’s
fpriority?
a. Loosen fthe fclothing faround fthe fclient’s fneck
b. Check fthe fclient’s fpupillary fresponse
c. Turn fthe fclient fto fthe fside.
d. Move ffurniture faway ffrom fthe fclient
i. Loosen fthe fclothing faround fthe fclient's fneck: fThe fnurse fshould floosen
fanyfrestrictive fclothing fthe fclient fis fwearing fto fprevent finjury fto fthe
fclient. fHowever, fanother faction fis fthe fpriority.
ii. Check fthe fclient's fpupillary fresponse: fThe fnurse fshould fperform
fneurologic fchecks fafter fthe fseizure fto fmonitor fthe fclient's frecovery.
fHowever, fanotherfaction fis fthe fpriority.
iii. Turn fthe fclient fto fthe fside.: fThe fgreatest frisk fto fthis fclient fis fhypoxia
ffrom fan fimpaired fairway. fTherefore, fthe fpriority fintervention fthe fnurse
fshould ftake fis fto fplace fthe fclient fin fa fside-lying fposition fto fprevent
faspiration.
iv. Move ffurniture faway ffrom fthe fclient.: fAThe fnurse fshould fmove ffurniture
faway ffrom f the f client f to f prevent f self-injury. f However, f another f action f is
f the f priority.
6. A fnurse fis fproviding fteaching fto faclient fwho fhas fhypothyroidism fand fis freceiving flevothyroxine. fThe fnurse
fshouldfinstruct fthe fclient fthat fwhich fof fthe ffollowing fsupplements fcan finterfere fwith fthe feffectiveness fof
fthe fmedication?
a. Ginkgo fbiloba
b. Glucosamine
c. Calcium
d. Vitamin fC
i.
Ginkgo fbiloba
ii. Ginkgo f biloba f reduces f the f pain f associated f with f peripheral f vascular
f disease fby fpromoting fvasodilation. fIt fcan finteract fwith fmedications fthat
fhave fanticoagulant fproperties, fbut fit fis fnot fknown fto finterfere fwith fthe
fabsorptionfof flevothyroxine.
iii. Glucosamine: fGlucosamine ftreats fosteoarthritis fby fdecreasing
finflammationfand fstimulating fthe fbody's fproduction fof fsynovial ffluid fand
fcartilage. fIt fcan finteract fwith fmedications fthat fhave fantiplatelet for
, fanticoagulant fproperties, fbut fit fis fnot fknown fto finterfere fwith fthe
fabsorption fof flevothyroxine.
iv. Calcium:NSWER
v. Calcium flimits fthe fdevelopment fof fosteoporosis fin fclients fwho fare
fpostmenopausal fand fworks fas fan fantacid. fCalcium fsupplements fcan
finterfere
with fthe fmetabolism fof fa fnumber fof fmedications, fincluding flevothyroxine.
fThefnurse fshould finstruct fthe fclient fto favoid ftaking fcalcium fwithin f4 fhr fof
flevothyroxine fadministration.
vi. Vitamin fC: fVitamin fC fpromotes fwound fhealing. fIt fcan fcause fa ffalse
fnegativefin ffecal foccult fblood ftests, fbut fit fis fnot fknown fto finterfere fwith
fthe fabsorption
of f levothyroxine.
7. A fnurse fis fplanning fto firrigate fand fdress fa fclean, fgranulation fwound ffor fa fclient fwho fhas fa fpressure finjury.
fWhichfof fthe ffollowing factions fshould fthe fnurse ftake?
a. Apply fa fwet-to-dry fgauze fdressing
b. Irrigate fwith fhydrogen fperoxide fsolution
c. Use fa f30-ml fsyringe
d. Attach fa f24-gauge fangiocatheter fto fthe fsyringe.
f 8.
a. Apply f a f wet-to-dry f gauze f dressing.: f The f nurse f should f not f apply f wet-to-dry
f dressings fto f clean, f granulating f wounds f as f they f interrupt f viable, f healing f tissues
f when f they f arefremoved. f Appropriate f dressings f for f a f wound f that f is f developing
f granulation f tissue finclude fa fhydrocolloid fdressing fand fa ftransparent ffilm
fdressing.
b. Irrigate fwith f hydrogen fperoxide fsolution: fthe fnurse fshould fuse fhydrogen fperoxide
f to fclean f contaminated f surfaces. f Hydrogen f peroxide f should f not f be f used f on f a
f pressure finjury f wound f because f it f destroys f newly f granulated f tissue. f Instead,
f the f nurse f shouldfuse f solutions f specifically f designed f as f wound f cleansers f or f 0.9%
f sodium f chloride firrigation fto firrigate fthe fwound.
c. Use fa f30-mL fsyringe: fNSWERThe fnurse fshould fuse fa f30-mL fto f60-mL fsyringe
fwithfan f 18- f or f 19-gauge f catheter f to f deliver f the f ideal f pressure f of f 8 f pounds
f per f square finch f(psi) fwhen firrigating fa fwound. fTo fmaintain fhealthy
fgranulation ftissue, fthe fwound firrigation fshould fbe fdelivered fat fbetween f4 fand
f15 fpsi.
