ATI RN ADULT MEDICAL SURGICAL REVIEW |
COMPREHENSIVE EXAM PREP, REAL QUESTIONS
DETAILED ANSWERS (2025 EDITION)
1. When initiating seizure precautions for a client, which of the following is an essential
nursing action?
A. Place a padded tongue blade at the bedside.
B. Ensure the client has IV access.
C. Administer a PRN benzodiazepine immediately.
D. Restrain the client's limbs loosely.
Correct Answer: B
Rationale: Ensuring IV access is crucial for the rapid administration of emergency seizure
medications, such as benzodiazepines, if a seizure occurs.
2. A postoperative client has a hemoglobin (Hgb) level of 8 g/dL. What is the priority
nursing action?
A. Administer an iron supplement.
B. Report the finding to the provider.
C. Encourage deep breathing exercises.
D. Increase oral fluid intake.
,Correct Answer: B
Rationale: A Hgb of 8 g/dL postoperatively is a significant finding that must be reported to the
provider as it can indicate postoperative hemorrhage or anemia requiring immediate intervention.
3. A client has undergone extracorporeal shock wave lithotripsy (ESWL) for renal calculi.
What should the nurse instruct the client to expect?
A. The urine will be clear and yellow.
B. Stone fragments will be present in the urine.
C. There will be no need for follow-up.
D. Urinary output will cease temporarily.
Correct Answer: B
Rationale: ESWL works by breaking the stone into small fragments, which are then passed
through the urinary system and will be visible in the urine.
4. A client presents with anorexia, low-grade fever, night sweats, and a productive cough.
Which transmission-based precautions should the nurse initiate?
A. Contact Precautions
B. Droplet Precautions
C. Airborne Precautions
D. Standard Precautions
Correct Answer: C
Rationale: These manifestations are classic for tuberculosis, which is spread via airborne
droplets, requiring Airborne Precautions.
, 5. A new bag of total parenteral nutrition (TPN) is not available for a client. Which action
should the nurse take to prevent complications?
A. Administer dextrose 10% in water.
B. Discontinue all IV fluids.
C. Administer a bolus of 0.9% sodium chloride.
D. Administer the previous day's TPN solution.
Correct Answer: A
Rationale: Administering dextrose 10% in water prevents hypoglycemia that would occur if the
high-dextrose TPN infusion were stopped abruptly.
6. A client is prescribed levothyroxine. Which instruction should the nurse provide
regarding medication administration?
A. Take with food to avoid gastrointestinal upset.
B. Avoid taking calcium within 4 hours.
C. Take at bedtime for best absorption.
D. Crush the tablet if difficulty swallowing occurs.
Correct Answer: B
Rationale: Calcium can bind with levothyroxine in the gastrointestinal tract, significantly
interfering with its absorption and effectiveness.
7. A client is anxious and fighting the mechanical ventilator. What is the most appropriate
nursing instruction?
A. "Try to breathe out when the machine breathes in."
B. "Allow the machine to breathe for you."
, C. "We will sedate you if you cannot calm down."
D. "Your body will adjust; there is nothing to do."
Correct Answer: B
Rationale: Instructing the client to allow the machine to breathe for them reduces dyssynchrony,
decreases anxiety and restlessness, and promotes effective ventilation.
8. A client is taking enalapril. For which adverse effect should the nurse monitor?
A. Tachycardia
B. Orthostatic hypotension
C. Hypertension
D. Hyperkalemia
Correct Answer: B
Rationale: Orthostatic hypotension is a common adverse effect of ACE inhibitors like enalapril
due to vasodilation.
9. Which client finding contributes to delayed wound healing?
A. Urine output of 25 mL/hr
B. Heart rate of 72/min
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 16/min
Correct Answer: A
Rationale: A urine output of 25 mL/hr indicates poor renal perfusion and dehydration, which
impairs the delivery of oxygen and nutrients necessary for wound healing.
COMPREHENSIVE EXAM PREP, REAL QUESTIONS
DETAILED ANSWERS (2025 EDITION)
1. When initiating seizure precautions for a client, which of the following is an essential
nursing action?
A. Place a padded tongue blade at the bedside.
B. Ensure the client has IV access.
C. Administer a PRN benzodiazepine immediately.
D. Restrain the client's limbs loosely.
Correct Answer: B
Rationale: Ensuring IV access is crucial for the rapid administration of emergency seizure
medications, such as benzodiazepines, if a seizure occurs.
2. A postoperative client has a hemoglobin (Hgb) level of 8 g/dL. What is the priority
nursing action?
A. Administer an iron supplement.
B. Report the finding to the provider.
C. Encourage deep breathing exercises.
D. Increase oral fluid intake.
,Correct Answer: B
Rationale: A Hgb of 8 g/dL postoperatively is a significant finding that must be reported to the
provider as it can indicate postoperative hemorrhage or anemia requiring immediate intervention.
3. A client has undergone extracorporeal shock wave lithotripsy (ESWL) for renal calculi.
What should the nurse instruct the client to expect?
A. The urine will be clear and yellow.
B. Stone fragments will be present in the urine.
C. There will be no need for follow-up.
D. Urinary output will cease temporarily.
Correct Answer: B
Rationale: ESWL works by breaking the stone into small fragments, which are then passed
through the urinary system and will be visible in the urine.
4. A client presents with anorexia, low-grade fever, night sweats, and a productive cough.
Which transmission-based precautions should the nurse initiate?
A. Contact Precautions
B. Droplet Precautions
C. Airborne Precautions
D. Standard Precautions
Correct Answer: C
Rationale: These manifestations are classic for tuberculosis, which is spread via airborne
droplets, requiring Airborne Precautions.
, 5. A new bag of total parenteral nutrition (TPN) is not available for a client. Which action
should the nurse take to prevent complications?
A. Administer dextrose 10% in water.
B. Discontinue all IV fluids.
C. Administer a bolus of 0.9% sodium chloride.
D. Administer the previous day's TPN solution.
Correct Answer: A
Rationale: Administering dextrose 10% in water prevents hypoglycemia that would occur if the
high-dextrose TPN infusion were stopped abruptly.
6. A client is prescribed levothyroxine. Which instruction should the nurse provide
regarding medication administration?
A. Take with food to avoid gastrointestinal upset.
B. Avoid taking calcium within 4 hours.
C. Take at bedtime for best absorption.
D. Crush the tablet if difficulty swallowing occurs.
Correct Answer: B
Rationale: Calcium can bind with levothyroxine in the gastrointestinal tract, significantly
interfering with its absorption and effectiveness.
7. A client is anxious and fighting the mechanical ventilator. What is the most appropriate
nursing instruction?
A. "Try to breathe out when the machine breathes in."
B. "Allow the machine to breathe for you."
, C. "We will sedate you if you cannot calm down."
D. "Your body will adjust; there is nothing to do."
Correct Answer: B
Rationale: Instructing the client to allow the machine to breathe for them reduces dyssynchrony,
decreases anxiety and restlessness, and promotes effective ventilation.
8. A client is taking enalapril. For which adverse effect should the nurse monitor?
A. Tachycardia
B. Orthostatic hypotension
C. Hypertension
D. Hyperkalemia
Correct Answer: B
Rationale: Orthostatic hypotension is a common adverse effect of ACE inhibitors like enalapril
due to vasodilation.
9. Which client finding contributes to delayed wound healing?
A. Urine output of 25 mL/hr
B. Heart rate of 72/min
C. Blood pressure of 120/80 mm Hg
D. Respiratory rate of 16/min
Correct Answer: A
Rationale: A urine output of 25 mL/hr indicates poor renal perfusion and dehydration, which
impairs the delivery of oxygen and nutrients necessary for wound healing.
