ATI NCLEX REVIEW MED SURG 2025
EXAM\ACCURATE ACTUAL EXAM
WITH FREQUENTLY TESTED
QUESTIONS AND STUDY GUIDE
\EXPERT VERIFIED FOR GUARANTEED
PASS\ALREADY GRADED A+
A nurse is assisting with the care of a client who was admitted to the emergency department with
reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence
of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how
many hours after the onset of chest pain?
24 hr
Rationale: The nurse can anticipate that CK-MB will peak 18 to 24 hr after the onset of chest pain
when acute myocardial infarction occurs.
A nurse is teaching an assistive personnel about attaching a footboard to the bed of a client who is
immobile. Which of the following information should the nurse include in the teaching?
"The footboard will help to prevent plantar flexion."
Rationale: The nurse should teach that the purpose of a footboard is to prevent plantar flexion
contracture or foot drop.
A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic
effect. The nurse should issue which of the following statements about the provider's use of the
international normalized ratio (INR)?
"This is a standardized test, so it eliminates the variations different laboratories report in prothrombin
times."
Rationale: The nurse should reinforce to the client that the INR is a standardized test, which means
that the result will be the same, no matter which laboratory performs this test.
, A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should
the nurse take?
Withhold food and liquids until the client's gag reflex returns.
Rationale: Until the gag reflex returns, the client is at high risk for aspirating food or fluids, therefore
the nurse should withhold food and liquids until the client’s gag reflex returns.
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which
of the following clients has a manifestation of a wound infection?
A client who has swelling and tenderness around the wound
Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness
around the wound, and a failure to heal.
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the
following findings should the nurse expect?
Oliguria
Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.
A nurse is reinforcing teaching with a client who is scheduled for a blood test to measure her thyroid-
stimulating hormone (TSH) level. Which of the following statements should the nurse give?
"The test determines whether your thyroid gland is overactive, appropriately active, or underactive."
Rationale: This statement describes this test, which helps determine thyroid status and helps monitor
the effectiveness and dosage of thyroid hormone replacement therapy.
A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the
following actions should the nurse take?
Allow the client to keep her hearing aids in.
Rationale: The nurse should allow the client to retain possession of her hearing aids so that she will be
able to hear and understand instructions given to her. The nurse should notify the surgical team and
place a note on the front of the chart and the pre-operative checklist indicating that hearing aids were
left in.
A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the
following findings is an indication of a wound infection?
Edema
Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness around
the wound, and a failure to heal.
EXAM\ACCURATE ACTUAL EXAM
WITH FREQUENTLY TESTED
QUESTIONS AND STUDY GUIDE
\EXPERT VERIFIED FOR GUARANTEED
PASS\ALREADY GRADED A+
A nurse is assisting with the care of a client who was admitted to the emergency department with
reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence
of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how
many hours after the onset of chest pain?
24 hr
Rationale: The nurse can anticipate that CK-MB will peak 18 to 24 hr after the onset of chest pain
when acute myocardial infarction occurs.
A nurse is teaching an assistive personnel about attaching a footboard to the bed of a client who is
immobile. Which of the following information should the nurse include in the teaching?
"The footboard will help to prevent plantar flexion."
Rationale: The nurse should teach that the purpose of a footboard is to prevent plantar flexion
contracture or foot drop.
A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic
effect. The nurse should issue which of the following statements about the provider's use of the
international normalized ratio (INR)?
"This is a standardized test, so it eliminates the variations different laboratories report in prothrombin
times."
Rationale: The nurse should reinforce to the client that the INR is a standardized test, which means
that the result will be the same, no matter which laboratory performs this test.
, A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should
the nurse take?
Withhold food and liquids until the client's gag reflex returns.
Rationale: Until the gag reflex returns, the client is at high risk for aspirating food or fluids, therefore
the nurse should withhold food and liquids until the client’s gag reflex returns.
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which
of the following clients has a manifestation of a wound infection?
A client who has swelling and tenderness around the wound
Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness
around the wound, and a failure to heal.
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following of the
following findings should the nurse expect?
Oliguria
Rationale: Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.
A nurse is reinforcing teaching with a client who is scheduled for a blood test to measure her thyroid-
stimulating hormone (TSH) level. Which of the following statements should the nurse give?
"The test determines whether your thyroid gland is overactive, appropriately active, or underactive."
Rationale: This statement describes this test, which helps determine thyroid status and helps monitor
the effectiveness and dosage of thyroid hormone replacement therapy.
A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the
following actions should the nurse take?
Allow the client to keep her hearing aids in.
Rationale: The nurse should allow the client to retain possession of her hearing aids so that she will be
able to hear and understand instructions given to her. The nurse should notify the surgical team and
place a note on the front of the chart and the pre-operative checklist indicating that hearing aids were
left in.
A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the
following findings is an indication of a wound infection?
Edema
Rationale: Manifestations of infection include purulent drainage, swelling, warmth, tenderness around
the wound, and a failure to heal.
