ATI RN Adult Medical Surgical Exam
Questions & Answers with Rationale
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT ANSWER >>Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is hypertension. The
prevalence of hypertension is highest among African American clients, followed by Caucasian
clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the
nurse that the client's condition is improving? - <CORRECT ANSWER >>Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of
the following findings should the nurse report to the provider immediately? - <CORRECT
ANSWER >>Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or possible
obstruction caused by edema or laryngeal spasms. The nurse should report the finding
immediately and implement an intervention.
, A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the
following findings should the nurse report to the provider? - <CORRECT ANSWER >>The client
reports back pain
Rationale: The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission
precautions should the nurse initiate? - <CORRECT ANSWER >>Airborne
Rationale: Airborne precautions are required for clients who have infections due to micro-
organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis,
measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care? - <CORRECT
ANSWER >>Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room in case
of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority? - <CORRECT ANSWER >>Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is an elevated temperature. An elevated temperature is a
manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
metabolic rate. The nurse should report this finding immediately to the provider because it can
lead to seizures and coma.
A nurse is providing discharge teaching about infection prevention to a client who has AIDS.
Which of the following statements by the client indicates understanding of the teaching? -
<CORRECT ANSWER >>"I will no longer floss my teeth after brushing my teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
Questions & Answers with Rationale
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty.
Which of the following instructions should the nurse include? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT 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? - <CORRECT ANSWER >>Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is hypertension. The
prevalence of hypertension is highest among African American clients, followed by Caucasian
clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the
nurse that the client's condition is improving? - <CORRECT ANSWER >>Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of
the following findings should the nurse report to the provider immediately? - <CORRECT
ANSWER >>Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or possible
obstruction caused by edema or laryngeal spasms. The nurse should report the finding
immediately and implement an intervention.
, A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the
following findings should the nurse report to the provider? - <CORRECT ANSWER >>The client
reports back pain
Rationale: The nurse should notify the provider if the client reports back pain, which can
indicate that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission
precautions should the nurse initiate? - <CORRECT ANSWER >>Airborne
Rationale: Airborne precautions are required for clients who have infections due to micro-
organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis,
measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care? - <CORRECT
ANSWER >>Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room in case
of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority? - <CORRECT ANSWER >>Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is an elevated temperature. An elevated temperature is a
manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
metabolic rate. The nurse should report this finding immediately to the provider because it can
lead to seizures and coma.
A nurse is providing discharge teaching about infection prevention to a client who has AIDS.
Which of the following statements by the client indicates understanding of the teaching? -
<CORRECT ANSWER >>"I will no longer floss my teeth after brushing my teeth."
Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum
inflammation, which could create the opportunity for infection.
