ATI-Style Medical-
Surgical Nursing &
Complex Care
Assessment
**Question 1**
The nurse is caring for a client with a diagnosis of acute respiratory distress syndrome (ARDS). Which
assessment finding is most consistent with this condition?
A. Bilateral crackles and hypoxemia refractory to oxygen therapy
B. Wheezing and prolonged expiratory phase
,C. Diminished breath sounds and barrel chest
D. Stridor and use of accessory muscles
💫RATIONALE✔️✔️: ARDS is characterized by diffuse alveolar damage leading to pulmonary edema,
bilateral crackles, and severe hypoxemia that does not improve with oxygen therapy. Wheezing and
prolonged expiration are more consistent with asthma or COPD. Diminished breath sounds and barrel
chest are more consistent with COPD. Stridor is associated with upper airway obstruction.
💫ANSWER✔️✔️: A. Bilateral crackles and hypoxemia refractory to oxygen therapy
---
**Question 2**
The nurse is caring for a client with a diagnosis of acute pancreatitis. Which intervention is the priority?
A. Maintaining NPO status and providing IV fluids
B. Administering oral fluids to prevent dehydration
C. Encouraging ambulation to promote bowel motility
D. Placing the client in a high-Fowler's position
💫RATIONALE✔️✔️: In acute pancreatitis, the pancreas needs to rest. Maintaining NPO status and
providing IV fluids to prevent dehydration and support circulation is the priority. Oral fluids would
stimulate pancreatic secretions and worsen pain. Ambulation is not a priority in the acute phase. Pain
management and fluid resuscitation are essential.
💫ANSWER✔️✔️: A. Maintaining NPO status and providing IV fluids
,---
**Question 3**
The nurse is assessing a client with a diagnosis of chronic kidney disease (CKD). Which laboratory finding
is most concerning?
A. Serum potassium of 5.5 mEq/L
B. Serum calcium of 10.5 mg/dL
C. Serum sodium of 135 mEq/L
D. Serum phosphorus of 3.5 mg/dL
💫RATIONALE✔️✔️: Hyperkalemia (serum potassium >5.0 mEq/L) is a life-threatening complication
of CKD due to decreased renal excretion. It can cause cardiac arrhythmias and requires immediate
intervention. The other values are within or near normal limits. Hyperkalemia is a common cause of
cardiac arrest in CKD patients.
💫ANSWER✔️✔️: A. Serum potassium of 5.5 mEq/L
---
**Question 4**
The nurse is providing education to a client with a new diagnosis of heart failure. Which statement
indicates the client understands the importance of sodium restriction?
A. "I can eat canned soups as long as I drink extra water."
, B. "I should avoid adding salt to my food at the table."
C. "I can use salt substitutes freely."
D. "I should limit my sodium intake to 3,000 mg per day."
💫RATIONALE✔️✔️: Avoiding adding salt to food at the table is an important part of sodium
restriction. Canned soups are high in sodium and should be avoided. Salt substitutes contain potassium
and should be used cautiously. The recommended sodium intake for heart failure is typically 1,500-
2,000 mg per day. Sodium restriction helps prevent fluid retention and worsening heart failure.
💫ANSWER✔️✔️: B. "I should avoid adding salt to my food at the table."
---
**Question 5**
The nurse is caring for a client with a central venous catheter (CVC). Which assessment finding requires
immediate intervention?
A. The insertion site is slightly red
B. The client's temperature is 99.5°F (37.5°C)
C. The client reports chest pain and dyspnea
D. The CVC dressing is dry and intact
💫RATIONALE✔️✔️: Chest pain and dyspnea in a client with a CVC may indicate a pneumothorax, air
embolism, or catheter migration. This requires immediate intervention. Slight redness and a low-grade
fever may indicate infection but are not as immediately life-threatening. The CVC should be assessed for
patency and proper placement.
Surgical Nursing &
Complex Care
Assessment
**Question 1**
The nurse is caring for a client with a diagnosis of acute respiratory distress syndrome (ARDS). Which
assessment finding is most consistent with this condition?
A. Bilateral crackles and hypoxemia refractory to oxygen therapy
B. Wheezing and prolonged expiratory phase
,C. Diminished breath sounds and barrel chest
D. Stridor and use of accessory muscles
💫RATIONALE✔️✔️: ARDS is characterized by diffuse alveolar damage leading to pulmonary edema,
bilateral crackles, and severe hypoxemia that does not improve with oxygen therapy. Wheezing and
prolonged expiration are more consistent with asthma or COPD. Diminished breath sounds and barrel
chest are more consistent with COPD. Stridor is associated with upper airway obstruction.
💫ANSWER✔️✔️: A. Bilateral crackles and hypoxemia refractory to oxygen therapy
---
**Question 2**
The nurse is caring for a client with a diagnosis of acute pancreatitis. Which intervention is the priority?
A. Maintaining NPO status and providing IV fluids
B. Administering oral fluids to prevent dehydration
C. Encouraging ambulation to promote bowel motility
D. Placing the client in a high-Fowler's position
💫RATIONALE✔️✔️: In acute pancreatitis, the pancreas needs to rest. Maintaining NPO status and
providing IV fluids to prevent dehydration and support circulation is the priority. Oral fluids would
stimulate pancreatic secretions and worsen pain. Ambulation is not a priority in the acute phase. Pain
management and fluid resuscitation are essential.
💫ANSWER✔️✔️: A. Maintaining NPO status and providing IV fluids
,---
**Question 3**
The nurse is assessing a client with a diagnosis of chronic kidney disease (CKD). Which laboratory finding
is most concerning?
A. Serum potassium of 5.5 mEq/L
B. Serum calcium of 10.5 mg/dL
C. Serum sodium of 135 mEq/L
D. Serum phosphorus of 3.5 mg/dL
💫RATIONALE✔️✔️: Hyperkalemia (serum potassium >5.0 mEq/L) is a life-threatening complication
of CKD due to decreased renal excretion. It can cause cardiac arrhythmias and requires immediate
intervention. The other values are within or near normal limits. Hyperkalemia is a common cause of
cardiac arrest in CKD patients.
💫ANSWER✔️✔️: A. Serum potassium of 5.5 mEq/L
---
**Question 4**
The nurse is providing education to a client with a new diagnosis of heart failure. Which statement
indicates the client understands the importance of sodium restriction?
A. "I can eat canned soups as long as I drink extra water."
, B. "I should avoid adding salt to my food at the table."
C. "I can use salt substitutes freely."
D. "I should limit my sodium intake to 3,000 mg per day."
💫RATIONALE✔️✔️: Avoiding adding salt to food at the table is an important part of sodium
restriction. Canned soups are high in sodium and should be avoided. Salt substitutes contain potassium
and should be used cautiously. The recommended sodium intake for heart failure is typically 1,500-
2,000 mg per day. Sodium restriction helps prevent fluid retention and worsening heart failure.
💫ANSWER✔️✔️: B. "I should avoid adding salt to my food at the table."
---
**Question 5**
The nurse is caring for a client with a central venous catheter (CVC). Which assessment finding requires
immediate intervention?
A. The insertion site is slightly red
B. The client's temperature is 99.5°F (37.5°C)
C. The client reports chest pain and dyspnea
D. The CVC dressing is dry and intact
💫RATIONALE✔️✔️: Chest pain and dyspnea in a client with a CVC may indicate a pneumothorax, air
embolism, or catheter migration. This requires immediate intervention. Slight redness and a low-grade
fever may indicate infection but are not as immediately life-threatening. The CVC should be assessed for
patency and proper placement.
