ATI RN ADULT MEDICAL SURGICAL EXAM WITH
VERIFIED AND DETAILED RATIONATE ANSWERS
2025-2026
A nurse is providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following information should the nurse include in the teaching? -
ANSWER "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of
verapamil. The client should increase fiber intake to promote regular bowel function.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include? - ANSWER Walk for 30 min four times per
week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help the
client prevent osteoporosis.
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following? - ANSWER Calf pain
Numbness in the arm
Intense headache
Rationale: Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client
should report this finding to the provider immediately.
Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular
accident, which is an adverse effect of hormone replacement therapy. The client should
report this finding to the provider immediately.
Intense headache is correct. An intense headache can indicate a cerebrovascular accident,
which is an adverse effect of hormone replacement therapy. The client should report this
finding to the provider immediately.
,A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The
nurse should identify the need to revise the plan for which of the following clients? -
ANSWER A client who is postoperative following abdominal surgery and reports feeling that
something "popped" when they coughed
Rationale: A feeling of something popping or loosening with coughing might indicate a
wound dehiscence. This client will need to have revisions to the plan of care, which can
include management of the dehiscence, prevention of evisceration, or possible surgical
repair of an evisceration if one occurs.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? - ANSWER Flex the foot every
hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk
for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion? - ANSWER Bubbling in
the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for
this therapy? - ANSWER INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial
infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an
anticoagulant, the medication must be monitored to ensure the anticoagulation is within the
therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or
, PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2
to 3 for a client who has atrial fibrillation.
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? - ANSWER 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 is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider? - ANSWER 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? - ANSWER 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? - ANSWER Hypertension
VERIFIED AND DETAILED RATIONATE ANSWERS
2025-2026
A nurse is providing teaching to a client who has hypertension and a new prescription for
verapamil. Which of the following information should the nurse include in the teaching? -
ANSWER "Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of
verapamil. The client should increase fiber intake to promote regular bowel function.
A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include? - ANSWER Walk for 30 min four times per
week.
Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help the
client prevent osteoporosis.
A nurse is providing teaching to a client who is perimenopausal and has a prescription for
hormone replacement therapy. For which of the following? - ANSWER Calf pain
Numbness in the arm
Intense headache
Rationale: Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client
should report this finding to the provider immediately.
Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular
accident, which is an adverse effect of hormone replacement therapy. The client should
report this finding to the provider immediately.
Intense headache is correct. An intense headache can indicate a cerebrovascular accident,
which is an adverse effect of hormone replacement therapy. The client should report this
finding to the provider immediately.
,A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The
nurse should identify the need to revise the plan for which of the following clients? -
ANSWER A client who is postoperative following abdominal surgery and reports feeling that
something "popped" when they coughed
Rationale: A feeling of something popping or loosening with coughing might indicate a
wound dehiscence. This client will need to have revisions to the plan of care, which can
include management of the dehiscence, prevention of evisceration, or possible surgical
repair of an evisceration if one occurs.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? - ANSWER Flex the foot every
hour when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk
for thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion? - ANSWER Bubbling in
the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for
this therapy? - ANSWER INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial
infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an
anticoagulant, the medication must be monitored to ensure the anticoagulation is within the
therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or
, PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2
to 3 for a client who has atrial fibrillation.
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? - ANSWER 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 is assessing a client following the completion of hemodialysis. Which of the
following findings is the nurse's priority to report to the provider? - ANSWER 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? - ANSWER 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? - ANSWER Hypertension
