ATI MED SURG Actual Exam 2 (2025) comprehensive questions and verified answers (
detailed & elaborated) 2025-2026 TEST
A nurse is assessing a client who is receiving a transfusion of packed red
blood cells (RBC). Which of the following findings should the nurse identify as
an indication of an acute intravascular hemolytic reaction?
sudden oliguria
rationale: indication fo acute intravascular hemolytic reaction. AKI
A nurse is planning care for a client who has pernicious anemia. Which of the
following interventions should the nurse include in the plan?
initiate weekly injections of vitamin B12
A nurse is caring for a client who is receiving IV ampicillin and develops
urticaria and dyspnea. Which of the following actions should the nurse take
first?
stop the medication infusion
A nurse is assessing the hematologic system of an older adult client. The
nurse should report which of the following findings to the provider as a
possible indication of a hematologic disorder?
Absence of hair on the legs
rationale: indicates poor arterial circulation to that area
A nurse is providing teaching about lifestyle changes to a client who
experienced a myocardial infarction and has a new perception for a beta block.
Which of the following client statements indicates an understanding of the
teaching?
Before taking my medication. I will count my radial pulse rate.
A nurse is caring for a client following a stroke. Which of the following actions
should the nurse take first?
Keep the client NPO
A nurse is planning care for a client during a sickle cell crisis. Which of the
following interventions should the nurse include in the clients plan of care?
encourage increased fluid intake
, A nurse is assessing a client who has fluid volume overload from a
cardiovascular disorder. Which of the following manifestations should the
nurse expect? select all that apply
jugular vein distension
moist crackles
increased heart rate
A nurse is caring for a client who has survey. Which of the following vitamin
deficiencies should the nurse identify as the cause of the disease?
Vitamin C
A nurse is transfusing a unit of O negative fresh frozen plasma (FFP) to a
client whose blood type is B positive. Which of the following actions should
the nurse take?
Remove the unit of plasma immediately and start an IV infusion of normal saline
solution
rationale: can experience a hemolytic transfusion reaction.
A nurse is admitting a client who is in sickle cell crisis. Besides pain
management which of the following interventions should the nurse include in
the client's plan of care?
ample hydration
A nurse observes tachycardia, dyspnea, a cough and distended neck being in
a client who is receiving a transfusion of packed red blood cells (RBC's).
Which of the following interventions should the nurse use to prevent these
manifestations with the client's next transfusion?
Use a transfusion pump to regulate and maintain the transfusion at a slower rate.
A nurse is providing discharge teaching for a client who has a newly inserted
permanent pacemaker. Which of the following instructions should the nurse
include in the teaching?
Keep your cell phone 6 inches away from your pace maker when making a call.
A nurse is caring for an older adult client who had an acute myocardial
infarction (MI). When assessing this client the nurse should identify that older
adults are prone to complications of MI from Poor tissue perfusion because of
which of the following age related factors?
Peripheral vascular resistance increases
detailed & elaborated) 2025-2026 TEST
A nurse is assessing a client who is receiving a transfusion of packed red
blood cells (RBC). Which of the following findings should the nurse identify as
an indication of an acute intravascular hemolytic reaction?
sudden oliguria
rationale: indication fo acute intravascular hemolytic reaction. AKI
A nurse is planning care for a client who has pernicious anemia. Which of the
following interventions should the nurse include in the plan?
initiate weekly injections of vitamin B12
A nurse is caring for a client who is receiving IV ampicillin and develops
urticaria and dyspnea. Which of the following actions should the nurse take
first?
stop the medication infusion
A nurse is assessing the hematologic system of an older adult client. The
nurse should report which of the following findings to the provider as a
possible indication of a hematologic disorder?
Absence of hair on the legs
rationale: indicates poor arterial circulation to that area
A nurse is providing teaching about lifestyle changes to a client who
experienced a myocardial infarction and has a new perception for a beta block.
Which of the following client statements indicates an understanding of the
teaching?
Before taking my medication. I will count my radial pulse rate.
A nurse is caring for a client following a stroke. Which of the following actions
should the nurse take first?
Keep the client NPO
A nurse is planning care for a client during a sickle cell crisis. Which of the
following interventions should the nurse include in the clients plan of care?
encourage increased fluid intake
, A nurse is assessing a client who has fluid volume overload from a
cardiovascular disorder. Which of the following manifestations should the
nurse expect? select all that apply
jugular vein distension
moist crackles
increased heart rate
A nurse is caring for a client who has survey. Which of the following vitamin
deficiencies should the nurse identify as the cause of the disease?
Vitamin C
A nurse is transfusing a unit of O negative fresh frozen plasma (FFP) to a
client whose blood type is B positive. Which of the following actions should
the nurse take?
Remove the unit of plasma immediately and start an IV infusion of normal saline
solution
rationale: can experience a hemolytic transfusion reaction.
A nurse is admitting a client who is in sickle cell crisis. Besides pain
management which of the following interventions should the nurse include in
the client's plan of care?
ample hydration
A nurse observes tachycardia, dyspnea, a cough and distended neck being in
a client who is receiving a transfusion of packed red blood cells (RBC's).
Which of the following interventions should the nurse use to prevent these
manifestations with the client's next transfusion?
Use a transfusion pump to regulate and maintain the transfusion at a slower rate.
A nurse is providing discharge teaching for a client who has a newly inserted
permanent pacemaker. Which of the following instructions should the nurse
include in the teaching?
Keep your cell phone 6 inches away from your pace maker when making a call.
A nurse is caring for an older adult client who had an acute myocardial
infarction (MI). When assessing this client the nurse should identify that older
adults are prone to complications of MI from Poor tissue perfusion because of
which of the following age related factors?
Peripheral vascular resistance increases
