MED SURG- PROCTORED ATI ACTUAL EXAM
QUESTIONS AND 100% CORRECT
ANSWERS|LATEST 2025/2026|GRADED A+
An older adult is brought to an emergency department by a family member. Which of the follo
B B B B B B B B B B B B B B B B
wing assessment findings should cause the nurse to suspect that the client has hypertonic deh
B B B B B B B B B B B B B B
ydration? - ANSWER- B B Urine Specific gravity 1.045B B B B
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increas
B B B B B B B B B B B B B B B
e in osmolarity, which is a manifestation of hypertonic dehydration.
B B B B B B B B B
A nurse in a community clinic is caring for a client who reports an increase in the frequency of
B B B B B B B B B B B B B B B B B B B
migraine headaches. To help reduce the risk for migraine headaches, which of the following fo
B B B B B B B B B B B B B B
ods should the nurse recommend the client avoid? - ANSWER-
B B B B B B B B B Aged cheese B
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headache
B B B B B B B B B B B B B
s.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous
B B B B B B B B B B B B B B B B B
diversion procedure to establish a ureterostomy. Which of the following statements should th
B B B B B B B B B B B B B
e nurse include in the teaching? - ANSWER-
B B B B B B B
"You should cut the opening of the skin barrier one-eight inch wider than the stoma."
B B B B B B B B B B B B B B B
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to mi
B B B B B B B B B B B B B B B B B B
nimize irritation of the skin from exposure to urine.
B B B B B B B B
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxin
B B B B B B B B B B B B B B
e. The nurse should instruct the client that which of the following supplements can interfere w
B B B B B B B B B B B B B B B
ith the effectiveness of the medication? - ANSWER-
B B B B B B B Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
B B B B B B B B B B B B
Bas an antacid. Calcium supplements can interfere with the metabolism of a number of medica
B B B B B B B B B B B B B B
tions, including levothyroxine. The nurse should instruct the client to avoid taking calcium wit
B B B B B B B B B B B B B
hin 4 hr of levothyroxine administration.
B B B B B
,A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV c
B B B B B B B B B B B B B B B B B B B B
ontrast agent. The nurse should identify that which of the following findings requires further a
B B B B B B B B B B B B B B
ssessment? - ANSWER- B B History of asthma B B B
A client who has a history of asthma has a greater risk of reacting to the contrast dye used duri
B B B B B B B B B B B B B B B B B B B
ng the procedure. Other conditions that can result in a reaction to contrast media include aller
B B B B B B B B B B B B B B B
gies to foods, such as shellfish, eggs, milk, and chocolate.
B B B B B B B B B
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following f
B B B B B B B B B B B B B B B B B B B
indings should the nurse identify as a component of Cushing's triad? - ANSWER-
B B B B B B B B B B B B
Bradycardia B
A client who has increased intracranial pressure from a traumatic brain injury can develop bra
B B B B B B B B B B B B B B
dycardia, which is one component of Cushing's triad. The other components of Cushing's triad
B B B B B B B B B B B B B
are severe hypertension and a widened pulse pressure.
B B B B B B B B
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a press
B B B B B B B B B B B B B B B B B B
ure injury. Which of the following actions should the nurse take? - ANSWER-
B B B B B B B B B B B B Use a 30- B B
mL syringe B B
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-
B B B B B B B B B B B B B
gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating
B B B B B B B B B B B B B B B B B
a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at b
B B B B B B B B B B B B B B
etween 4 and 15 psi. B B B B
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
B B B B B B B B B B B B B B B
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the e
B B B B B B B B B B B B B B B
xpect? - ANSWER- B B Administer an opioid analgesic to the client. B B B B B B B
The nurse should expect a prescription for an opioid analgesic to promote comfort following a
B B B B B B B B B B B B B B B
rattlesnake bite. B
,A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
B B B B B B B B B B B B B B B B B B
nurse should postpone the testing and report to the provider which of the following findings?
B B B B B B B B B B B B B B B
(Click on the "Exhibit" button for additional information about the client). - ANSWER-
B B B B B B B B B B B B
Current medications B B
The nurse should review the client's medication record and identify medications, including AC
B B B B B B B B B B B B
E inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, t
B B B B B B B B B B B
hat can alter the allergy skin test results. These medications can diminish the client's reaction t
B B B B B B B B B B B B B B B
o the allergens. The nurse should notify the provider and instruct the client to discontinue pre
B B B B B B B B B B B B B B B
dnisone for 2 weeks before allergy skin testing.
B B B B B B B
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin sub
B B B B B B B B B B B B B B B B B B B B
cutaneous. Which of the following actions should the nurse take? - ANSWER-
B B B B B B B B B B B
Inject the medication into the anterolateral abdominal wall.
B B B B B B B B
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
B B B B B B B B B B B B
to enhance medication absorption and prevent hematoma formation.
B B B B B B B B
A nurse is caring for a client who has a stage III pressure injury. Which if the following findings
B B B B B B B B B B B B B B B B B B B
contribute to delayed wound healing? - ANSWER- B B B B B B Urine output 25 mL/hr B B B B
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which
B B B B B B B B B B B B
can delay wound healing.
B B B
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). Th
B B B B B B B B B B B B B B B B B
e client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump should b
B B B B B B B B B B B B B B B B B B
e set at how many mL/hr? (Rounding to the nearest whole number.) - ANSWER-
B B B B B B B B B B B B B
167 mL/hr B
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this ri
B B B B B B B B B B B B B B B B B B
sk, which of the following dietary alterations should the nurse recommend? - ANSWER-
B B B B B B B B B B B B
Add cabbage to the diet.
B B B B B
, To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fib
B B B B B B B B B B B B B B B B B B
er, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage, cauliflow
B B B B B B B B B B B B B B
er, and broccoli, are high in fiber.
B B B B B B
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied t
B B B B B B B B B B B B B B B B B B
o her burn wounds. The nurse should evaluate the client for which of the following laboratory
B B B B B B B B B B B B B B B B
findings? - ANSWER- B B Leukopenia B
Transient leukopenia is an adverse effect of silver sulfadiazine.
B B B B B B B B
A nurse is teaching a client with systemic erythematosus who has a new prescription for predn
B B B B B B B B B B B B B B B
isone. The nurse should instruct the client to monitor for which of the following adverse effect
B B B B B B B B B B B B B B B
s of this medication? - ANSWER-
B B B B B Infection B
The nurse should instruct the client to avoid contact with people who are ill and monitor for m
B B B B B B B B B B B B B B B B B
anifestations of an infection such as a fever or a sore throat. Prednisone can suppress the clien
B B B B B B B B B B B B B B B B
t's immune response and mask the manifestations of an infection.
B B B B B B B B B
A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy.
B B B B B B B B B B B B B B B
Which of the following statements indicates that the client understands the impact of the surg
B B B B B B B B B B B B B B
ery? - ANSWER- B B
"I understand that I will have a permanent tracheostomy after the surgery."
B B B B B B B B B B B B
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryng
B B B B B B B B B B B B B B
ectomy, so the tracheostomy will be permanent.
B B B B B B
A nurse is assessing a client who has systemic scleroderma. Which of the following findings sh
B B B B B B B B B B B B B B B
ould the nurse expect? - ANSWER-
B B B B B Finger contractures B
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the ski
B B B B B B B B B B B B B B
n, blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma,
B B B B B B B B B B B B B
which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Ma
B B B B B B B B B B B B B B
nifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dr
B B B B B B B B B B
QUESTIONS AND 100% CORRECT
ANSWERS|LATEST 2025/2026|GRADED A+
An older adult is brought to an emergency department by a family member. Which of the follo
B B B B B B B B B B B B B B B B
wing assessment findings should cause the nurse to suspect that the client has hypertonic deh
B B B B B B B B B B B B B B
ydration? - ANSWER- B B Urine Specific gravity 1.045B B B B
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increas
B B B B B B B B B B B B B B B
e in osmolarity, which is a manifestation of hypertonic dehydration.
B B B B B B B B B
A nurse in a community clinic is caring for a client who reports an increase in the frequency of
B B B B B B B B B B B B B B B B B B B
migraine headaches. To help reduce the risk for migraine headaches, which of the following fo
B B B B B B B B B B B B B B
ods should the nurse recommend the client avoid? - ANSWER-
B B B B B B B B B Aged cheese B
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headache
B B B B B B B B B B B B B
s.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous
B B B B B B B B B B B B B B B B B
diversion procedure to establish a ureterostomy. Which of the following statements should th
B B B B B B B B B B B B B
e nurse include in the teaching? - ANSWER-
B B B B B B B
"You should cut the opening of the skin barrier one-eight inch wider than the stoma."
B B B B B B B B B B B B B B B
The client should cut the opening of the skin barrier 0.3 cm (1/8in) wider than the stoma to mi
B B B B B B B B B B B B B B B B B B
nimize irritation of the skin from exposure to urine.
B B B B B B B B
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxin
B B B B B B B B B B B B B B
e. The nurse should instruct the client that which of the following supplements can interfere w
B B B B B B B B B B B B B B B
ith the effectiveness of the medication? - ANSWER-
B B B B B B B Calcium
Calcium limits the development of osteoporosis in clients who are postmenopausal and works
B B B B B B B B B B B B
Bas an antacid. Calcium supplements can interfere with the metabolism of a number of medica
B B B B B B B B B B B B B B
tions, including levothyroxine. The nurse should instruct the client to avoid taking calcium wit
B B B B B B B B B B B B B
hin 4 hr of levothyroxine administration.
B B B B B
,A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV c
B B B B B B B B B B B B B B B B B B B B
ontrast agent. The nurse should identify that which of the following findings requires further a
B B B B B B B B B B B B B B
ssessment? - ANSWER- B B History of asthma B B B
A client who has a history of asthma has a greater risk of reacting to the contrast dye used duri
B B B B B B B B B B B B B B B B B B B
ng the procedure. Other conditions that can result in a reaction to contrast media include aller
B B B B B B B B B B B B B B B
gies to foods, such as shellfish, eggs, milk, and chocolate.
B B B B B B B B B
A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following f
B B B B B B B B B B B B B B B B B B B
indings should the nurse identify as a component of Cushing's triad? - ANSWER-
B B B B B B B B B B B B
Bradycardia B
A client who has increased intracranial pressure from a traumatic brain injury can develop bra
B B B B B B B B B B B B B B
dycardia, which is one component of Cushing's triad. The other components of Cushing's triad
B B B B B B B B B B B B B
are severe hypertension and a widened pulse pressure.
B B B B B B B B
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a press
B B B B B B B B B B B B B B B B B B
ure injury. Which of the following actions should the nurse take? - ANSWER-
B B B B B B B B B B B B Use a 30- B B
mL syringe B B
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-
B B B B B B B B B B B B B
gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating
B B B B B B B B B B B B B B B B B
a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at b
B B B B B B B B B B B B B B
etween 4 and 15 psi. B B B B
A nurse in an emergency department is reviewing the provider's prescriptions for a client who
B B B B B B B B B B B B B B B
sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the e
B B B B B B B B B B B B B B B
xpect? - ANSWER- B B Administer an opioid analgesic to the client. B B B B B B B
The nurse should expect a prescription for an opioid analgesic to promote comfort following a
B B B B B B B B B B B B B B B
rattlesnake bite. B
,A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The
B B B B B B B B B B B B B B B B B B
nurse should postpone the testing and report to the provider which of the following findings?
B B B B B B B B B B B B B B B
(Click on the "Exhibit" button for additional information about the client). - ANSWER-
B B B B B B B B B B B B
Current medications B B
The nurse should review the client's medication record and identify medications, including AC
B B B B B B B B B B B B
E inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, t
B B B B B B B B B B B
hat can alter the allergy skin test results. These medications can diminish the client's reaction t
B B B B B B B B B B B B B B B
o the allergens. The nurse should notify the provider and instruct the client to discontinue pre
B B B B B B B B B B B B B B B
dnisone for 2 weeks before allergy skin testing.
B B B B B B B
A nurse is a caring for a client who is on bed rest and has a new prescription for enoxaparin sub
B B B B B B B B B B B B B B B B B B B B
cutaneous. Which of the following actions should the nurse take? - ANSWER-
B B B B B B B B B B B
Inject the medication into the anterolateral abdominal wall.
B B B B B B B B
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall
B B B B B B B B B B B B
to enhance medication absorption and prevent hematoma formation.
B B B B B B B B
A nurse is caring for a client who has a stage III pressure injury. Which if the following findings
B B B B B B B B B B B B B B B B B B B
contribute to delayed wound healing? - ANSWER- B B B B B B Urine output 25 mL/hr B B B B
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which
B B B B B B B B B B B B
can delay wound healing.
B B B
A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). Th
B B B B B B B B B B B B B B B B B
e client is to receive 2,000 kcal per day. The TPN solution has 500kcal/L. The IV pump should b
B B B B B B B B B B B B B B B B B B
e set at how many mL/hr? (Rounding to the nearest whole number.) - ANSWER-
B B B B B B B B B B B B B
167 mL/hr B
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this ri
B B B B B B B B B B B B B B B B B B
sk, which of the following dietary alterations should the nurse recommend? - ANSWER-
B B B B B B B B B B B B
Add cabbage to the diet.
B B B B B
, To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fib
B B B B B B B B B B B B B B B B B B
er, low in fat, and low in refined carbohydrates. Brassica vegetables such as cabbage, cauliflow
B B B B B B B B B B B B B B
er, and broccoli, are high in fiber.
B B B B B B
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied t
B B B B B B B B B B B B B B B B B B
o her burn wounds. The nurse should evaluate the client for which of the following laboratory
B B B B B B B B B B B B B B B B
findings? - ANSWER- B B Leukopenia B
Transient leukopenia is an adverse effect of silver sulfadiazine.
B B B B B B B B
A nurse is teaching a client with systemic erythematosus who has a new prescription for predn
B B B B B B B B B B B B B B B
isone. The nurse should instruct the client to monitor for which of the following adverse effect
B B B B B B B B B B B B B B B
s of this medication? - ANSWER-
B B B B B Infection B
The nurse should instruct the client to avoid contact with people who are ill and monitor for m
B B B B B B B B B B B B B B B B B
anifestations of an infection such as a fever or a sore throat. Prednisone can suppress the clien
B B B B B B B B B B B B B B B B
t's immune response and mask the manifestations of an infection.
B B B B B B B B B
A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy.
B B B B B B B B B B B B B B B
Which of the following statements indicates that the client understands the impact of the surg
B B B B B B B B B B B B B B
ery? - ANSWER- B B
"I understand that I will have a permanent tracheostomy after the surgery."
B B B B B B B B B B B B
With a partial laryngectomy, the tracheostomy is temporary. This client will have a total laryng
B B B B B B B B B B B B B B
ectomy, so the tracheostomy will be permanent.
B B B B B B
A nurse is assessing a client who has systemic scleroderma. Which of the following findings sh
B B B B B B B B B B B B B B B
ould the nurse expect? - ANSWER-
B B B B B Finger contractures B
Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the ski
B B B B B B B B B B B B B B
n, blood vessels, and internal organs. There are 2 types of scleroderma: localized scleroderma,
B B B B B B B B B B B B B
which mainly affects the skin, and systemic scleroderma, which can affect internal organs. Ma
B B B B B B B B B B B B B B
nifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dr
B B B B B B B B B B
