ATI NCLEX Medical Surgical Assessment 1
UPDATED ACTUAL Questions and
CORRECT Answers
A nurse is planning care for a client receiving mechanical ventilation. Which action should the
nurse include in the plan - CORRECT ANSWER Provide means of communication using
electronic tablet, speech generating device, alphabet board, pencil and paper, etc
A nurse is caring for a client receiving IV fluid replacement therapy for dehydration. Which
laboratory result indicates effectiveness of treatment - CORRECT ANSWER Urine
specific gravity 1.020, within expected range of 1.005-1.030
A nurse is monitoring lab findings for a client postoperative following total hip arthroplasty.
Which value indicates increased risk for bleeding - CORRECT ANSWER Platelets 80,000,
range is 150,000-400,000
A nurse is admitting a client with a cervical spinal cord injury following a motor vehicle crash.
What intervention is the nurse's priority - CORRECT ANSWER Assist client with quad
coughing to ensure airway clearance
A nurse is caring for a client receiving a blood transfusion. Which finding indicates transfusion-
associated circulatory overload - CORRECT ANSWER Dyspnea, indicating possible
circulatory overload or transfusion-related lung injury
A nurse is assessing a client with lung cancer undergoing radiation therapy to the chest. What
indicates an adverse effect of therapy - CORRECT ANSWER Altered taste sensations due
to release of metabolites by dead cells
A nurse is preparing to administer packed RBCs to a client with anemia. Which actions should
the nurse plan to take - CORRECT ANSWER Obtain pre-transfusion temperature, verify
client's blood type, use 20 gauge IV needle for venous access
, A nurse is reviewing lab findings for a dehydrated client. What BUN level should the nurse
expect - CORRECT ANSWER 26 mg/dL, elevated levels indicate various conditions
including dehydration
A nurse is reviewing ECG strips for clients. Which image indicates atrial fibrillation -
CORRECT ANSWER Multiple irregular waves at baseline and irregular R to R intervals
A nurse is preparing to admit a client with a new tracheostomy. What item is the priority to have
available in the client's room upon admission - CORRECT ANSWER Obturator for
emergency airway maintenance in case of dislodgment or decannulation
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2
days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image - CORRECT ANSWER Tell me how the
changes to your leg make you feel
A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which
of the following instructions should the nurse include - CORRECT ANSWER Wait at least
30 to 60 seconds between puffs of the medication. Wait 2-5 min between using different
medications from separate inhalers
A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy
for colon cancer screening. Which of the following information should the nurse provide -
CORRECT ANSWER You will need someone to drive you home after your procedure
A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the
following findings requires immediate intervention by the nurse - CORRECT
ANSWER No response to verbal stimuli
A nurse is reviewing the laboratory findings for a client who has heart failure and is taking
furosemide. The nurse should identify which of the following findings as an adverse effect of the
medication - CORRECT ANSWER Potassium 3.2 mEq/L
UPDATED ACTUAL Questions and
CORRECT Answers
A nurse is planning care for a client receiving mechanical ventilation. Which action should the
nurse include in the plan - CORRECT ANSWER Provide means of communication using
electronic tablet, speech generating device, alphabet board, pencil and paper, etc
A nurse is caring for a client receiving IV fluid replacement therapy for dehydration. Which
laboratory result indicates effectiveness of treatment - CORRECT ANSWER Urine
specific gravity 1.020, within expected range of 1.005-1.030
A nurse is monitoring lab findings for a client postoperative following total hip arthroplasty.
Which value indicates increased risk for bleeding - CORRECT ANSWER Platelets 80,000,
range is 150,000-400,000
A nurse is admitting a client with a cervical spinal cord injury following a motor vehicle crash.
What intervention is the nurse's priority - CORRECT ANSWER Assist client with quad
coughing to ensure airway clearance
A nurse is caring for a client receiving a blood transfusion. Which finding indicates transfusion-
associated circulatory overload - CORRECT ANSWER Dyspnea, indicating possible
circulatory overload or transfusion-related lung injury
A nurse is assessing a client with lung cancer undergoing radiation therapy to the chest. What
indicates an adverse effect of therapy - CORRECT ANSWER Altered taste sensations due
to release of metabolites by dead cells
A nurse is preparing to administer packed RBCs to a client with anemia. Which actions should
the nurse plan to take - CORRECT ANSWER Obtain pre-transfusion temperature, verify
client's blood type, use 20 gauge IV needle for venous access
, A nurse is reviewing lab findings for a dehydrated client. What BUN level should the nurse
expect - CORRECT ANSWER 26 mg/dL, elevated levels indicate various conditions
including dehydration
A nurse is reviewing ECG strips for clients. Which image indicates atrial fibrillation -
CORRECT ANSWER Multiple irregular waves at baseline and irregular R to R intervals
A nurse is preparing to admit a client with a new tracheostomy. What item is the priority to have
available in the client's room upon admission - CORRECT ANSWER Obturator for
emergency airway maintenance in case of dislodgment or decannulation
A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2
days ago. Which of the following statements should the nurse use to assess how the client is
coping with this change in their body image - CORRECT ANSWER Tell me how the
changes to your leg make you feel
A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which
of the following instructions should the nurse include - CORRECT ANSWER Wait at least
30 to 60 seconds between puffs of the medication. Wait 2-5 min between using different
medications from separate inhalers
A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy
for colon cancer screening. Which of the following information should the nurse provide -
CORRECT ANSWER You will need someone to drive you home after your procedure
A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the
following findings requires immediate intervention by the nurse - CORRECT
ANSWER No response to verbal stimuli
A nurse is reviewing the laboratory findings for a client who has heart failure and is taking
furosemide. The nurse should identify which of the following findings as an adverse effect of the
medication - CORRECT ANSWER Potassium 3.2 mEq/L
