ATI RN ADULT MEDICAL-SURGICAL NURSING
TEST BANK COMPREHENSIVE EXAM PREP
WITH 100% VERIFIED SOLUTIONS 2026
◉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? 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? 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? 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? 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? 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? 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? 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? 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.
TEST BANK COMPREHENSIVE EXAM PREP
WITH 100% VERIFIED SOLUTIONS 2026
◉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? 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? 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? 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? 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? 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? 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? 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? 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.
