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2025 - 2026 ATI RN ADULT MEDICAL SURGICAL
EXAM|NEWEST UPDATE|90Qs&As|A+GRADE PASS
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? Flex the foot every hour when awake. Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. 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? 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? INR 2. 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? 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? 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? 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 caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the following findings should the nurse report to the provider? The client reports back pain Rationale: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged. A nurse is admitting a client who has active TB. Which of the following types of transmission precautions should the nurse initiate? Airborne Rationale: Airborne precautions are required for clients who have infections due to micro- organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster. A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room Rationale: The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma. A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? "I will no longer floss my teeth after brushing my teeth." Rationale: The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection. A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? "Increase fiber intake to avoid constipation." Rationale: The nurse should instruct the client that constipation is an adverse effect of verapamil. The client should increase fiber intake to promote regular bowel function. A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Walk for 30 min four times per week. Rationale: Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? Constipation Rationale: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation. A nurse is caring for a client who has cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? Heart Rate 52/min Rationale: A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing. A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? Place a pressure bag around the flush solutions Rationale: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider?
Serum creatinine Rationale: A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic. A nurse is preparing to administer phenytoin 600 mg PO daily to a client. he amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? 24 Rationale: Desired/have x mL A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? "I will refer you to community resources that can provide support." Rationale: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes. A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? Encourage the client to take deep breaths after the procedure. Rationale: After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. Rationale: The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of he following complications is associated with long-term mechanical ventilation? Stress ulcers Rationale: Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment. A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity Rationale: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which f the following findings should the nurse identify as a manifestation of this condition? Pain that increases with passive movement Rationale: The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Irrigate the indwelling urinary catheter. Rationale: The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow. A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? The client's heart rate increases. Rationale: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? Report of a sore throat Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? "I will eat more high-fiber foods" Rationale: The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements. A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Low back pain and apprehension Rationale: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? "I will use an electric razor to shave." Rationale: Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin. A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? Prednisone Rationale: The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium. A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? "Ibuprofen can cause gastrointestinal bleeding in older adult clients." Rationale: A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.
Extremely cool upon palpation Rationale: The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome. A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A tingling sensation replacing the pain Rationale: A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain. A nurse is caring for a client who has homonymous hemianopsia as result of a stroke. To reduce the risk of falls when ambulating the nurse should provide which of the following instructions to the client? "Scan the environment by turning your head from side to side." Rationale: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
PaCO2 56mmHg Rationale: A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? Hair loss on the lower legs Rationale: The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Avocados Rationale: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. A nurse is planning care for a client who is postoperative following laparotomy and has a closed-suction drain. which of the following actions should the nurse take to manage the drain? Compress the drain reservoir after emptying.
decisions about their treatment and the nurse should support these decisions and assist the client to carry them out. A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? Warfarin Rationale: Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery. A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? WBC count 2,000/mm Rationale: A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression. A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? Check the client's neurologic status. Rationale: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client.
A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? Drink 240 mL (8 oz) of water after administration. Rationale: The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid. A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) Following a smoke cessation program Maintain an appropriate weight Eat a low-fat diet Rationale: Follow a smoking cessation program is correct. Smoking cessation is an important lifestyle modification to prevent atherosclerosis. Maintain an appropriate weight is correct. Preventing obesity through diet and exercise can help to prevent atherosclerosis. Eat a low-fat diet is correct. Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.
