ATI Med-Surg Retake Exam – 60 Verified
Questions with Nursing Rationales | 100%
Correct Solutions | Graded A | 2025
Edition
Question 1:
A nurse is assessing a client who is 4 hours postoperative after abdominal surgery. The client
reports sudden shortness of breath and chest pain. Which action should the nurse take first?
A. Administer oxygen via nasal cannula.
B. Assess the client's vital signs.
C. Notify the rapid response team.
D. Encourage deep breathing exercises.
■ Correct Answer: B
Rationale: Assessing vital signs first provides baseline data to identify instability, such as
tachycardia or hypotension, which may indicate pulmonary embolism in the postoperative period.
Question 2:
A nurse is caring for a client postoperative following a cholecystectomy. The client has an
abdominal drain in place. Which finding should the nurse report to the provider?
A. Serosanguineous drainage of 50 mL in 24 hours.
B. Output that is bright red and increasing.
C. Drainage that is clear and amber in color.
D. Minimal drainage with intermittent flow.
■ Correct Answer: B
Rationale: Bright red, increasing drainage suggests active bleeding, which requires immediate
intervention to prevent hypovolemia.
Question 3:
A nurse is reinforcing teaching about incentive spirometry to a client who is postoperative day 1
after a thoracotomy. Which statement by the client indicates understanding?
A. "I should use it every 2 hours while awake."
B. "I need to cough forcefully after each use."
C. "It helps prevent fluid buildup in my lungs."
D. "I'll only use it if I feel short of breath."
■ Correct Answer: C
,Rationale: Incentive spirometry promotes lung expansion to prevent atelectasis and pneumonia
by mobilizing secretions.
Question 4:
A client who is 2 days postoperative after a knee replacement reports numbness and tingling in
the operative leg. Which action should the nurse prioritize?
A. Apply a warm compress to the leg.
B. Elevate the leg above heart level.
C. Assess for signs of compartment syndrome.
D. Administer prescribed analgesic medication.
■ Correct Answer: C
Rationale: Numbness and tingling are early signs of compartment syndrome, a surgical
emergency requiring immediate assessment to prevent tissue damage.
Question 5:
A nurse is monitoring a client who underwent a laparoscopic appendectomy. The client suddenly
develops shoulder pain. What is the nurse's best action?
A. Reposition the client to the left side.
B. Administer antiemetic medication.
C. Reassure the client it is normal.
D. Prepare for possible CO2 insufflation release.
■ Correct Answer: C
Rationale: Referred shoulder pain from diaphragmatic irritation due to residual CO2 is a
common postoperative occurrence after laparoscopy and typically resolves spontaneously.
Question 6:
A nurse is caring for a client postoperative following a total hip arthroplasty. To prevent
dislocation, the nurse should instruct the client to avoid which position?
A. Supine with legs extended.
B. Adducted leg with hip flexed beyond 90 degrees.
C. Prone position with pillows under the abdomen.
D. Side-lying with an abductor pillow in place.
■ Correct Answer: B
Rationale: Adduction and flexion beyond 90 degrees increase the risk of posterior hip dislocation
in the early postoperative period.
Question 7:
A client 6 hours postoperative after a colectomy develops tachycardia and hypotension. The
nurse suspects hypovolemia. Which intervention is priority?
A. Increase IV fluid rate.
B. Administer oxygen at 2 L/min.
C. Assess for abdominal distention.
, D. Encourage oral fluid intake.
■ Correct Answer: C
Rationale: Abdominal distention may indicate internal bleeding or ileus, contributing to
hypovolemia, and requires immediate evaluation.
Question 8:
A nurse is preparing a client for discharge after a herniorrhaphy. Which instruction is most
important for preventing wound dehiscence?
A. Avoid lifting objects over 10 pounds for 4 weeks.
B. Apply ice to the incision site daily.
C. Take acetaminophen for any discomfort.
D. Wear loose clothing over the site.
■ Correct Answer: A
Rationale: Heavy lifting increases intra-abdominal pressure, which can lead to wound
dehiscence in the healing phase.
Question 9:
A client postoperative following a mastectomy is at risk for lymphedema. Which action should
the nurse include in the care plan?
A. Measure blood pressure on the affected arm.
B. Encourage vigorous arm exercises on day 1.
C. Apply elastic bandages to the arm.
D. Elevate the affected arm above heart level.
■ Correct Answer: D
Rationale: Elevation promotes venous and lymphatic drainage, reducing swelling and the risk of
lymphedema.
Question 10:
A nurse is assessing a client 12 hours postoperative after a cesarean section. The client has a
boggy uterus. What is the priority nursing action?
A. Massage the fundus.
B. Administer oxytocin IV.
C. Encourage ambulation.
D. Assess lochia flow.
■ Correct Answer: A
Rationale: Fundal massage expresses clots and promotes uterine contraction to control
postpartum hemorrhage.
Question 11:
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) experiencing
an acute exacerbation. Which oxygen delivery method is most appropriate?
A. Non-rebreather mask at 100%.
Questions with Nursing Rationales | 100%
Correct Solutions | Graded A | 2025
Edition
Question 1:
A nurse is assessing a client who is 4 hours postoperative after abdominal surgery. The client
reports sudden shortness of breath and chest pain. Which action should the nurse take first?
A. Administer oxygen via nasal cannula.
B. Assess the client's vital signs.
C. Notify the rapid response team.
D. Encourage deep breathing exercises.
■ Correct Answer: B
Rationale: Assessing vital signs first provides baseline data to identify instability, such as
tachycardia or hypotension, which may indicate pulmonary embolism in the postoperative period.
Question 2:
A nurse is caring for a client postoperative following a cholecystectomy. The client has an
abdominal drain in place. Which finding should the nurse report to the provider?
A. Serosanguineous drainage of 50 mL in 24 hours.
B. Output that is bright red and increasing.
C. Drainage that is clear and amber in color.
D. Minimal drainage with intermittent flow.
■ Correct Answer: B
Rationale: Bright red, increasing drainage suggests active bleeding, which requires immediate
intervention to prevent hypovolemia.
Question 3:
A nurse is reinforcing teaching about incentive spirometry to a client who is postoperative day 1
after a thoracotomy. Which statement by the client indicates understanding?
A. "I should use it every 2 hours while awake."
B. "I need to cough forcefully after each use."
C. "It helps prevent fluid buildup in my lungs."
D. "I'll only use it if I feel short of breath."
■ Correct Answer: C
,Rationale: Incentive spirometry promotes lung expansion to prevent atelectasis and pneumonia
by mobilizing secretions.
Question 4:
A client who is 2 days postoperative after a knee replacement reports numbness and tingling in
the operative leg. Which action should the nurse prioritize?
A. Apply a warm compress to the leg.
B. Elevate the leg above heart level.
C. Assess for signs of compartment syndrome.
D. Administer prescribed analgesic medication.
■ Correct Answer: C
Rationale: Numbness and tingling are early signs of compartment syndrome, a surgical
emergency requiring immediate assessment to prevent tissue damage.
Question 5:
A nurse is monitoring a client who underwent a laparoscopic appendectomy. The client suddenly
develops shoulder pain. What is the nurse's best action?
A. Reposition the client to the left side.
B. Administer antiemetic medication.
C. Reassure the client it is normal.
D. Prepare for possible CO2 insufflation release.
■ Correct Answer: C
Rationale: Referred shoulder pain from diaphragmatic irritation due to residual CO2 is a
common postoperative occurrence after laparoscopy and typically resolves spontaneously.
Question 6:
A nurse is caring for a client postoperative following a total hip arthroplasty. To prevent
dislocation, the nurse should instruct the client to avoid which position?
A. Supine with legs extended.
B. Adducted leg with hip flexed beyond 90 degrees.
C. Prone position with pillows under the abdomen.
D. Side-lying with an abductor pillow in place.
■ Correct Answer: B
Rationale: Adduction and flexion beyond 90 degrees increase the risk of posterior hip dislocation
in the early postoperative period.
Question 7:
A client 6 hours postoperative after a colectomy develops tachycardia and hypotension. The
nurse suspects hypovolemia. Which intervention is priority?
A. Increase IV fluid rate.
B. Administer oxygen at 2 L/min.
C. Assess for abdominal distention.
, D. Encourage oral fluid intake.
■ Correct Answer: C
Rationale: Abdominal distention may indicate internal bleeding or ileus, contributing to
hypovolemia, and requires immediate evaluation.
Question 8:
A nurse is preparing a client for discharge after a herniorrhaphy. Which instruction is most
important for preventing wound dehiscence?
A. Avoid lifting objects over 10 pounds for 4 weeks.
B. Apply ice to the incision site daily.
C. Take acetaminophen for any discomfort.
D. Wear loose clothing over the site.
■ Correct Answer: A
Rationale: Heavy lifting increases intra-abdominal pressure, which can lead to wound
dehiscence in the healing phase.
Question 9:
A client postoperative following a mastectomy is at risk for lymphedema. Which action should
the nurse include in the care plan?
A. Measure blood pressure on the affected arm.
B. Encourage vigorous arm exercises on day 1.
C. Apply elastic bandages to the arm.
D. Elevate the affected arm above heart level.
■ Correct Answer: D
Rationale: Elevation promotes venous and lymphatic drainage, reducing swelling and the risk of
lymphedema.
Question 10:
A nurse is assessing a client 12 hours postoperative after a cesarean section. The client has a
boggy uterus. What is the priority nursing action?
A. Massage the fundus.
B. Administer oxytocin IV.
C. Encourage ambulation.
D. Assess lochia flow.
■ Correct Answer: A
Rationale: Fundal massage expresses clots and promotes uterine contraction to control
postpartum hemorrhage.
Question 11:
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) experiencing
an acute exacerbation. Which oxygen delivery method is most appropriate?
A. Non-rebreather mask at 100%.
