ATI RN MEDSURG 2025 COMPREHENSIVE MULTIPLECHOICE
QUESTIONS WITH 100% RATED CORRECT ANSWERS 2025 LATEST
UPDATED GET IT CORRECT
Question 1
A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lbs) in the last 24 hours.
The client reports increased shortness of breath and has crackles bilaterally in the lung bases.
Which intervention should the nurse prioritize?
A) Administer a prescribed antianxiety medication.
B) Encourage ambulation to improve circulation.
C) Assess deep tendon reflexes.
D) Administer a prescribed loop diuretic.
E) Provide a low-sodium diet tray.
Correct Answer: D) Administer a prescribed loop diuretic.
Rationale: The client's symptoms (rapid weight gain, increased shortness of breath, bilateral
crackles) are indicative of acute fluid volume overload and worsening heart failure.
Administering a prescribed loop diuretic is the priority intervention to rapidly remove
excess fluid, reduce pulmonary congestion, and improve respiratory status.
Question 2
A client with type 2 diabetes mellitus is prescribed metformin. Which information is most
important for the nurse to include in the client's teaching plan?
A) "This medication may cause weight gain."
B) "Take this medication with a glass of milk."
C) "Stop taking metformin for 24-48 hours before and after any procedure involving IV contrast
dye."
D) "This medication stimulates insulin production from your pancreas."
E) "You can stop taking this medication once your blood glucose levels normalize."
Correct Answer: C) "Stop taking metformin for 24-48 hours before and after any procedure
involving IV contrast dye."
Rationale: Metformin carries a risk of lactic acidosis, especially in clients with impaired
renal function. IV contrast dye can cause acute kidney injury, so metformin must be held
before and for 24-48 hours after contrast administration to prevent this serious
complication. The other statements are incorrect or represent misunderstandings about
metformin.
Question 3
The nurse is caring for a client post-thyroidectomy. Which assessment finding requires
immediate intervention?
A) Client reports mild throat soreness.
B) Temperature of 99.0°F (37.2°C).
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C) Frequent swallowing and vocal changes beyond mild hoarseness.
D) Clear liquid intake of 120 mL.
E) Pain level of 3/10 with prescribed analgesia.
Correct Answer: C) Frequent swallowing and vocal changes beyond mild hoarseness.
Rationale: Frequent swallowing can indicate bleeding and hematoma formation in the
surgical site, which could compromise the client's airway. Significant vocal changes (e.g.,
stridor, severe hoarseness) suggest laryngeal nerve damage or airway swelling. Airway
compromise is the most critical complication post-thyroidectomy and requires immediate
assessment and intervention.
Question 4
A client with a deep vein thrombosis (DVT) in the right leg is prescribed enoxaparin. Which
instruction is essential for the nurse to provide regarding self-administration?
A) "Inject the medication into the deltoid muscle."
B) "Rub the injection site vigorously after administration."
C) "Administer the injection into the abdomen, pinching a skin fold, and do not rub the site
afterward."
D) "Take this medication orally with food."
E) "Inject the medication directly into the affected leg."
Correct Answer: C) "Administer the injection into the abdomen, pinching a skin fold, and
do not rub the site afterward."
Rationale: Enoxaparin (Lovenox) is a low molecular weight heparin administered via
subcutaneous injection. The preferred site is the abdomen, pinching a skin fold. The site
should not be rubbed after injection to prevent bruising and hematoma formation. It is not
given orally or IM.
Question 5
The nurse is assessing a client with acute pancreatitis. Which assessment finding would be a
priority to report to the healthcare provider?
A) Client reports persistent nausea.
B) Serum amylase level of 150 U/L (normal: 30-110 U/L).
C) Hypoactive bowel sounds.
D) Severe epigastric pain radiating to the back.
E) Client reports feeling anxious.
Correct Answer: D) Severe epigastric pain radiating to the back.
Rationale: Severe, persistent epigastric pain radiating to the back is the hallmark symptom
of acute pancreatitis. While other findings like nausea and elevated amylase (though 150 is
only slightly elevated) are consistent, the severity of pain and its characteristic radiation are
the most critical to report, as pain management is a top priority and its intensity indicates
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the acuteness of the condition. Elevated amylase/lipase are diagnostic, but severe pain is the
acute clinical presentation requiring attention.
Question 6
A client with chronic kidney disease (CKD) is experiencing pruritus (itching). Which nursing
intervention is most appropriate?
A) Encourage frequent hot showers.
B) Apply alcohol-based lotions.
C) Administer prescribed antihistamines and use emollients regularly.
D) Advise the client to vigorously scratch the itchy areas.
E) Recommend a high-protein diet.
Correct Answer: C) Administer prescribed antihistamines and use emollients regularly.
Rationale: Pruritus in CKD is often caused by the accumulation of uremic toxins.
Antihistamines can help reduce itching, and emollients (moisturizers) help keep the skin
hydrated and reduce dryness, which can exacerbate itching. Hot showers and alcohol-
based lotions can dry the skin. Vigorous scratching causes skin breakdown. A high-protein
diet may be restricted in CKD.
Question 7
The nurse is preparing to administer packed red blood cells (PRBCs) to a client. Which nursing
action is essential to ensure client safety?
A) Prime the transfusion tubing with 5% Dextrose in Water (D5W).
B) Infuse the PRBCs over a maximum of 6 hours.
C) Verify client identification and blood product with another licensed nurse.
D) Administer acetaminophen and diphenhydramine pre-transfusion as routine.
E) Warm the PRBCs to room temperature in a microwave.
Correct Answer: C) Verify client identification and blood product with another licensed
nurse.
Rationale: Verifying client identification and the blood product with another licensed nurse
(a "two-person check") is the most critical step to prevent a fatal transfusion reaction due
to ABO incompatibility. PRBCs should be infused within 2-4 hours, tubing primed with
normal saline, pre-meds are not routine, and blood warmers are specialized devices, not
microwaves.
Question 8
A client with a traumatic brain injury (TBI) develops bradycardia, hypertension, and a widened
pulse pressure. These findings are most indicative of:
A) Early signs of hypovolemic shock.
B) Cushing's triad, indicating increased intracranial pressure (ICP).
C) A normal compensatory response to cerebral injury.
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D) Improvement in neurological status.
E) Adverse reaction to pain medication.
Correct Answer: B) Cushing's triad, indicating increased intracranial pressure (ICP).
Rationale: Cushing's triad (bradycardia, hypertension, and a widened pulse pressure) is a
classic late sign of significantly increased intracranial pressure (ICP). It indicates
compression of the brainstem and impending herniation, which is a neurological
emergency.
Question 9
The nurse is providing discharge teaching to a client with newly diagnosed asthma. Which
statement indicates the client understands how to use their rescue inhaler (albuterol)?
A) "I should use my albuterol inhaler every morning to prevent asthma attacks."
B) "My albuterol inhaler is for treating inflammation in my lungs."
C) "I will use two puffs of albuterol if I feel short of breath or start wheezing."
D) "I need to rinse my mouth after using albuterol to prevent oral thrush."
E) "I should call 911 if my albuterol works after one dose."
Correct Answer: C) "I will use two puffs of albuterol if I feel short of breath or start
wheezing."
Rationale: Albuterol is a short-acting beta-agonist (SABA) and is used as a rescue
medication for acute asthma symptoms like shortness of breath, wheezing, or chest
tightness. It provides rapid bronchodilation. It's not for daily prevention, inflammation, or
requires rinsing the mouth (that's for inhaled corticosteroids).
Question 10
A client is admitted with diabetic ketoacidosis (DKA). The nurse anticipates which primary
intravenous fluid to be administered initially?
A) 0.45% Sodium Chloride (half-normal saline).
B) 0.9% Sodium Chloride (normal saline).
C) 5% Dextrose in Water (D5W).
D) Lactated Ringer's solution with potassium.
E) 5% Dextrose in 0.45% Sodium Chloride.
Correct Answer: B) 0.9% Sodium Chloride (normal saline).
Rationale: The initial treatment for DKA involves aggressive fluid resuscitation to correct
severe dehydration. 0.9% Sodium Chloride (normal saline) is the isotonic solution of choice
for rapid intravascular volume expansion. Dextrose-containing fluids are typically
introduced later when blood glucose levels drop to around 200-250 mg/dL to prevent
hypoglycemia.
Question 11
A client with a history of hypertension is prescribed a new antihypertensive medication. The
QUESTIONS WITH 100% RATED CORRECT ANSWERS 2025 LATEST
UPDATED GET IT CORRECT
Question 1
A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lbs) in the last 24 hours.
The client reports increased shortness of breath and has crackles bilaterally in the lung bases.
Which intervention should the nurse prioritize?
A) Administer a prescribed antianxiety medication.
B) Encourage ambulation to improve circulation.
C) Assess deep tendon reflexes.
D) Administer a prescribed loop diuretic.
E) Provide a low-sodium diet tray.
Correct Answer: D) Administer a prescribed loop diuretic.
Rationale: The client's symptoms (rapid weight gain, increased shortness of breath, bilateral
crackles) are indicative of acute fluid volume overload and worsening heart failure.
Administering a prescribed loop diuretic is the priority intervention to rapidly remove
excess fluid, reduce pulmonary congestion, and improve respiratory status.
Question 2
A client with type 2 diabetes mellitus is prescribed metformin. Which information is most
important for the nurse to include in the client's teaching plan?
A) "This medication may cause weight gain."
B) "Take this medication with a glass of milk."
C) "Stop taking metformin for 24-48 hours before and after any procedure involving IV contrast
dye."
D) "This medication stimulates insulin production from your pancreas."
E) "You can stop taking this medication once your blood glucose levels normalize."
Correct Answer: C) "Stop taking metformin for 24-48 hours before and after any procedure
involving IV contrast dye."
Rationale: Metformin carries a risk of lactic acidosis, especially in clients with impaired
renal function. IV contrast dye can cause acute kidney injury, so metformin must be held
before and for 24-48 hours after contrast administration to prevent this serious
complication. The other statements are incorrect or represent misunderstandings about
metformin.
Question 3
The nurse is caring for a client post-thyroidectomy. Which assessment finding requires
immediate intervention?
A) Client reports mild throat soreness.
B) Temperature of 99.0°F (37.2°C).
,[Type here]
C) Frequent swallowing and vocal changes beyond mild hoarseness.
D) Clear liquid intake of 120 mL.
E) Pain level of 3/10 with prescribed analgesia.
Correct Answer: C) Frequent swallowing and vocal changes beyond mild hoarseness.
Rationale: Frequent swallowing can indicate bleeding and hematoma formation in the
surgical site, which could compromise the client's airway. Significant vocal changes (e.g.,
stridor, severe hoarseness) suggest laryngeal nerve damage or airway swelling. Airway
compromise is the most critical complication post-thyroidectomy and requires immediate
assessment and intervention.
Question 4
A client with a deep vein thrombosis (DVT) in the right leg is prescribed enoxaparin. Which
instruction is essential for the nurse to provide regarding self-administration?
A) "Inject the medication into the deltoid muscle."
B) "Rub the injection site vigorously after administration."
C) "Administer the injection into the abdomen, pinching a skin fold, and do not rub the site
afterward."
D) "Take this medication orally with food."
E) "Inject the medication directly into the affected leg."
Correct Answer: C) "Administer the injection into the abdomen, pinching a skin fold, and
do not rub the site afterward."
Rationale: Enoxaparin (Lovenox) is a low molecular weight heparin administered via
subcutaneous injection. The preferred site is the abdomen, pinching a skin fold. The site
should not be rubbed after injection to prevent bruising and hematoma formation. It is not
given orally or IM.
Question 5
The nurse is assessing a client with acute pancreatitis. Which assessment finding would be a
priority to report to the healthcare provider?
A) Client reports persistent nausea.
B) Serum amylase level of 150 U/L (normal: 30-110 U/L).
C) Hypoactive bowel sounds.
D) Severe epigastric pain radiating to the back.
E) Client reports feeling anxious.
Correct Answer: D) Severe epigastric pain radiating to the back.
Rationale: Severe, persistent epigastric pain radiating to the back is the hallmark symptom
of acute pancreatitis. While other findings like nausea and elevated amylase (though 150 is
only slightly elevated) are consistent, the severity of pain and its characteristic radiation are
the most critical to report, as pain management is a top priority and its intensity indicates
,[Type here]
the acuteness of the condition. Elevated amylase/lipase are diagnostic, but severe pain is the
acute clinical presentation requiring attention.
Question 6
A client with chronic kidney disease (CKD) is experiencing pruritus (itching). Which nursing
intervention is most appropriate?
A) Encourage frequent hot showers.
B) Apply alcohol-based lotions.
C) Administer prescribed antihistamines and use emollients regularly.
D) Advise the client to vigorously scratch the itchy areas.
E) Recommend a high-protein diet.
Correct Answer: C) Administer prescribed antihistamines and use emollients regularly.
Rationale: Pruritus in CKD is often caused by the accumulation of uremic toxins.
Antihistamines can help reduce itching, and emollients (moisturizers) help keep the skin
hydrated and reduce dryness, which can exacerbate itching. Hot showers and alcohol-
based lotions can dry the skin. Vigorous scratching causes skin breakdown. A high-protein
diet may be restricted in CKD.
Question 7
The nurse is preparing to administer packed red blood cells (PRBCs) to a client. Which nursing
action is essential to ensure client safety?
A) Prime the transfusion tubing with 5% Dextrose in Water (D5W).
B) Infuse the PRBCs over a maximum of 6 hours.
C) Verify client identification and blood product with another licensed nurse.
D) Administer acetaminophen and diphenhydramine pre-transfusion as routine.
E) Warm the PRBCs to room temperature in a microwave.
Correct Answer: C) Verify client identification and blood product with another licensed
nurse.
Rationale: Verifying client identification and the blood product with another licensed nurse
(a "two-person check") is the most critical step to prevent a fatal transfusion reaction due
to ABO incompatibility. PRBCs should be infused within 2-4 hours, tubing primed with
normal saline, pre-meds are not routine, and blood warmers are specialized devices, not
microwaves.
Question 8
A client with a traumatic brain injury (TBI) develops bradycardia, hypertension, and a widened
pulse pressure. These findings are most indicative of:
A) Early signs of hypovolemic shock.
B) Cushing's triad, indicating increased intracranial pressure (ICP).
C) A normal compensatory response to cerebral injury.
, [Type here]
D) Improvement in neurological status.
E) Adverse reaction to pain medication.
Correct Answer: B) Cushing's triad, indicating increased intracranial pressure (ICP).
Rationale: Cushing's triad (bradycardia, hypertension, and a widened pulse pressure) is a
classic late sign of significantly increased intracranial pressure (ICP). It indicates
compression of the brainstem and impending herniation, which is a neurological
emergency.
Question 9
The nurse is providing discharge teaching to a client with newly diagnosed asthma. Which
statement indicates the client understands how to use their rescue inhaler (albuterol)?
A) "I should use my albuterol inhaler every morning to prevent asthma attacks."
B) "My albuterol inhaler is for treating inflammation in my lungs."
C) "I will use two puffs of albuterol if I feel short of breath or start wheezing."
D) "I need to rinse my mouth after using albuterol to prevent oral thrush."
E) "I should call 911 if my albuterol works after one dose."
Correct Answer: C) "I will use two puffs of albuterol if I feel short of breath or start
wheezing."
Rationale: Albuterol is a short-acting beta-agonist (SABA) and is used as a rescue
medication for acute asthma symptoms like shortness of breath, wheezing, or chest
tightness. It provides rapid bronchodilation. It's not for daily prevention, inflammation, or
requires rinsing the mouth (that's for inhaled corticosteroids).
Question 10
A client is admitted with diabetic ketoacidosis (DKA). The nurse anticipates which primary
intravenous fluid to be administered initially?
A) 0.45% Sodium Chloride (half-normal saline).
B) 0.9% Sodium Chloride (normal saline).
C) 5% Dextrose in Water (D5W).
D) Lactated Ringer's solution with potassium.
E) 5% Dextrose in 0.45% Sodium Chloride.
Correct Answer: B) 0.9% Sodium Chloride (normal saline).
Rationale: The initial treatment for DKA involves aggressive fluid resuscitation to correct
severe dehydration. 0.9% Sodium Chloride (normal saline) is the isotonic solution of choice
for rapid intravascular volume expansion. Dextrose-containing fluids are typically
introduced later when blood glucose levels drop to around 200-250 mg/dL to prevent
hypoglycemia.
Question 11
A client with a history of hypertension is prescribed a new antihypertensive medication. The
