ATI RN ADULT MEDICAL SURGICAL
EXAM NEWEST 2025 QUESTIONS
AND ANSWERS WITH RATIONELS
A nurse is providing postoperative teaching for a client who had a total
knee arthroplasty. Which of the following instructions should the nurse
include? - CORRECT ANSWER-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? - CORRECT 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? -
CORRECT 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? -
CORRECT 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? - CORRECT 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? - CORRECT
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?
- CORRECT 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? - CORRECT 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? - CORRECT 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.
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? - CORRECT ANSWER-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? -
CORRECT ANSWER-Airborne
EXAM NEWEST 2025 QUESTIONS
AND ANSWERS WITH RATIONELS
A nurse is providing postoperative teaching for a client who had a total
knee arthroplasty. Which of the following instructions should the nurse
include? - CORRECT ANSWER-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? - CORRECT 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? -
CORRECT 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? -
CORRECT 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? - CORRECT 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? - CORRECT
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?
- CORRECT 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? - CORRECT 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? - CORRECT 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.
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? - CORRECT ANSWER-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? -
CORRECT ANSWER-Airborne
