ATI Med Surg CMS Proctored Exam
Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
1. A nurse is assessing a client with heart failure who has
crackles in both lung bases and an S3 gallop. Which
intervention should the nurse implement first?
Answer: Place the client in high-Fowler’s position.
Rationale: High-Fowler’s position reduces venous return
(preload) and helps mobilize pulmonary secretions,
improving oxygenation. The S3 and crackles indicate fluid
overload; positioning is immediate and non-invasive.
2. A client with type 1 diabetes mellitus reports sweating,
tachycardia, and confusion. The client’s blood glucose is 52
mg/dL. What should the nurse give first?
Answer: 15 g of fast-acting carbohydrate (e.g., 4 oz orange
juice).
Rationale: The client is hypoglycemic. The Rule of 15 is
followed: give 15 g carbohydrate, recheck glucose in 15
minutes. Oral glucose is safest if the client can swallow.
,3. A nurse is caring for a client post-thyroidectomy who
reports numbness and tingling around the mouth. Which lab
value should the nurse check first?
Answer: Serum calcium.
Rationale: Numbness/tingling (paresthesia) suggests
hypocalcemia due to accidental removal of parathyroid
glands during thyroidectomy. Hypocalcemia can lead to
tetany and laryngospasm.
4. A client with COPD has a prescription for oxygen at 2 L/min
via nasal cannula. The client’s spouse asks why the flow is so
low. Which response is correct?
Answer: “High oxygen levels can decrease his drive to
breathe.”
Rationale: Clients with chronic hypercapnia rely on hypoxic
drive. High O₂ can suppress respiratory drive, leading to
apnea.
5. A nurse is teaching a client with a new ileostomy. Which
food should the client be advised to avoid?
Answer: Raw celery.
Rationale: High-fiber, stringy foods (celery, corn, popcorn)
can cause obstruction in an ileostomy because the small
bowel is narrower than the colon.
6. A client on warfarin has an INR of 4.5. The client has no
signs of bleeding. What should the nurse anticipate?
Answer: Hold the next dose of warfarin.
, Rationale: Therapeutic INR for most conditions is 2–3. INR
>4.5 without bleeding often requires holding the dose and
possibly giving vitamin K per protocol.
7. A nurse is suctioning a client with a tracheostomy. Which
action is correct?
Answer: Apply suction only while withdrawing the catheter.
Rationale: Applying suction during insertion increases the
risk of hypoxia, mucosal damage, and vagal stimulation.
8. A client with cirrhosis has ascites and an order for
furosemide. Which assessment finding is most important to
report?
Answer: Serum potassium of 3.1 mEq/L.
Rationale: Furosemide is a loop diuretic that can cause
hypokalemia. Low potassium increases the risk of
arrhythmias, especially in a client who may also have hepatic
encephalopathy.
9. A nurse is caring for a client with a chest tube to water-seal
drainage. The drainage chamber has continuous bubbling.
What should the nurse do?
Answer: Check the system for an air leak.
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak (e.g., loose connection, cracked tubing).
Intermittent bubbling with expiration is normal.
10. A client with acute pancreatitis reports severe abdominal
pain radiating to the back. The pain is not relieved by
vomiting. Which position should the nurse encourage?
, Answer: Side-lying with knees flexed (fetal position).
Rationale: The fetal position reduces tension on the
pancreas and mesentery, providing pain relief. Supine can
worsen pain.
11. A nurse is preparing to administer digoxin to a client with
heart failure. The client’s heart rate is 52 bpm and the apical
pulse is irregular. What should the nurse do?
Answer: Withhold the digoxin and notify the provider.
Rationale: Digoxin is held for heart rate <60 bpm in adults
(or <50 bpm in well-trained athletes) and for new irregular
rhythms, which may indicate digoxin toxicity.
12. A client with a new colostomy is reluctant to look at the
stoma. Which response by the nurse is most appropriate?
Answer: “I understand this is difficult. Many clients feel the
same way at first.”
Rationale: Acknowledging the client’s feelings without
pressure is therapeutic. Avoid false reassurance or forcing the
issue.
13. A nurse is caring for a client with tuberculosis who is
taking isoniazid and rifampin. Which instruction should the
nurse provide?
Answer: “Your tears and urine may turn orange.”
Rationale: Rifampin causes harmless orange-red
discoloration of body fluids. Clients need to know this to
avoid unnecessary alarm.
Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
1. A nurse is assessing a client with heart failure who has
crackles in both lung bases and an S3 gallop. Which
intervention should the nurse implement first?
Answer: Place the client in high-Fowler’s position.
Rationale: High-Fowler’s position reduces venous return
(preload) and helps mobilize pulmonary secretions,
improving oxygenation. The S3 and crackles indicate fluid
overload; positioning is immediate and non-invasive.
2. A client with type 1 diabetes mellitus reports sweating,
tachycardia, and confusion. The client’s blood glucose is 52
mg/dL. What should the nurse give first?
Answer: 15 g of fast-acting carbohydrate (e.g., 4 oz orange
juice).
Rationale: The client is hypoglycemic. The Rule of 15 is
followed: give 15 g carbohydrate, recheck glucose in 15
minutes. Oral glucose is safest if the client can swallow.
,3. A nurse is caring for a client post-thyroidectomy who
reports numbness and tingling around the mouth. Which lab
value should the nurse check first?
Answer: Serum calcium.
Rationale: Numbness/tingling (paresthesia) suggests
hypocalcemia due to accidental removal of parathyroid
glands during thyroidectomy. Hypocalcemia can lead to
tetany and laryngospasm.
4. A client with COPD has a prescription for oxygen at 2 L/min
via nasal cannula. The client’s spouse asks why the flow is so
low. Which response is correct?
Answer: “High oxygen levels can decrease his drive to
breathe.”
Rationale: Clients with chronic hypercapnia rely on hypoxic
drive. High O₂ can suppress respiratory drive, leading to
apnea.
5. A nurse is teaching a client with a new ileostomy. Which
food should the client be advised to avoid?
Answer: Raw celery.
Rationale: High-fiber, stringy foods (celery, corn, popcorn)
can cause obstruction in an ileostomy because the small
bowel is narrower than the colon.
6. A client on warfarin has an INR of 4.5. The client has no
signs of bleeding. What should the nurse anticipate?
Answer: Hold the next dose of warfarin.
, Rationale: Therapeutic INR for most conditions is 2–3. INR
>4.5 without bleeding often requires holding the dose and
possibly giving vitamin K per protocol.
7. A nurse is suctioning a client with a tracheostomy. Which
action is correct?
Answer: Apply suction only while withdrawing the catheter.
Rationale: Applying suction during insertion increases the
risk of hypoxia, mucosal damage, and vagal stimulation.
8. A client with cirrhosis has ascites and an order for
furosemide. Which assessment finding is most important to
report?
Answer: Serum potassium of 3.1 mEq/L.
Rationale: Furosemide is a loop diuretic that can cause
hypokalemia. Low potassium increases the risk of
arrhythmias, especially in a client who may also have hepatic
encephalopathy.
9. A nurse is caring for a client with a chest tube to water-seal
drainage. The drainage chamber has continuous bubbling.
What should the nurse do?
Answer: Check the system for an air leak.
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak (e.g., loose connection, cracked tubing).
Intermittent bubbling with expiration is normal.
10. A client with acute pancreatitis reports severe abdominal
pain radiating to the back. The pain is not relieved by
vomiting. Which position should the nurse encourage?
, Answer: Side-lying with knees flexed (fetal position).
Rationale: The fetal position reduces tension on the
pancreas and mesentery, providing pain relief. Supine can
worsen pain.
11. A nurse is preparing to administer digoxin to a client with
heart failure. The client’s heart rate is 52 bpm and the apical
pulse is irregular. What should the nurse do?
Answer: Withhold the digoxin and notify the provider.
Rationale: Digoxin is held for heart rate <60 bpm in adults
(or <50 bpm in well-trained athletes) and for new irregular
rhythms, which may indicate digoxin toxicity.
12. A client with a new colostomy is reluctant to look at the
stoma. Which response by the nurse is most appropriate?
Answer: “I understand this is difficult. Many clients feel the
same way at first.”
Rationale: Acknowledging the client’s feelings without
pressure is therapeutic. Avoid false reassurance or forcing the
issue.
13. A nurse is caring for a client with tuberculosis who is
taking isoniazid and rifampin. Which instruction should the
nurse provide?
Answer: “Your tears and urine may turn orange.”
Rationale: Rifampin causes harmless orange-red
discoloration of body fluids. Clients need to know this to
avoid unnecessary alarm.
