EXAM RETAKE 2 ATI RN MEDICAL SURGICAL MED SURG A
LATEST QUESTIONS WITH CORRECT DETAILED ANSWERS
WITH RATIONALES
Question 1
A nurse is caring for a client who is 2 days postoperative following an
abdominal colectomy. The client reports severe abdominal pain. Which non-
pharmacological intervention should the nurse prioritize to manage the pain?
A) Distraction with television.
B) Applying a cold compress to the abdomen.
C) Repositioning the client and ensuring proper body alignment.
D) Encouraging deep breathing exercises.
E) Providing aromatherapy.
Correct Answer: C) Repositioning the client and ensuring proper
body alignment.
Rationale: While all listed options (except cold compress for
abdominal pain) are non-pharmacological pain interventions,
repositioning and ensuring proper body alignment can directly
alleviate pressure on the surgical site and reduce muscular tension,
often providing significant immediate relief.
Question 2
A nurse is assessing a client with fluid volume deficit. Which of the following
findings would the nurse expect?
A) Bounding peripheral pulses.
B) Peripheral edema.
C) Dry mucous membranes and orthostatic hypotension.
D) Increased urine output.
E) Bradycardia.
Correct Answer: C) Dry mucous membranes and orthostatic
hypotension.
Rationale: Fluid volume deficit (dehydration) leads to decreased
circulating volume, resulting in dry mucous membranes, decreased
,skin turgor, orthostatic hypotension, tachycardia, and concentrated
urine with decreased output.
Question 3
A nurse is providing discharge teaching to a client with chronic obstructive
pulmonary disease (COPD). Which statement indicates the client
understands their oxygen therapy?
A) "I should increase my oxygen to 6 L/min if I feel short of breath."
B) "I will avoid using my oxygen unless I am very active."
C) "I should keep my oxygen flow rate as prescribed, usually 2-4 L/min via
nasal cannula, to avoid respiratory depression."
D) "It's okay to smoke while using my oxygen, as long as I'm careful."
E) "I only need my oxygen at night."
Correct Answer: C) "I should keep my oxygen flow rate as
prescribed, usually 2-4 L/min via nasal cannula, to avoid respiratory
depression."
Rationale: Clients with COPD may have a hypoxic drive to breathe.
High flow rates of oxygen can suppress this drive, leading to
hypoventilation and CO2 retention. Therefore, oxygen should be
used cautiously and at prescribed low flow rates.
Question 4
A nurse is caring for a client with hyperkalemia. Which ECG change would
the nurse anticipate?
A) Flattened T waves.
B) Prominent U waves.
C) Peaked T waves.
D) Shortened PR interval.
E) ST segment depression.
Correct Answer: C) Peaked T waves.
Rationale: Peaked, narrow T waves are a classic and often early ECG
,manifestation of hyperkalemia, indicating increased myocardial
irritability.
Question 5
A nurse is preparing to administer intravenous potassium chloride (KCl) to a
client. Which safety guideline is paramount for IV KCl administration?
A) Administer as an IV push for rapid correction.
B) Administer rapidly over 5 minutes.
C) Administer undiluted through a peripheral IV.
D) Never administer via IV push; always dilute and infuse slowly via an IV
pump.
E) Administer only through a central venous catheter.
Correct Answer: D) Never administer via IV push; always dilute and
infuse slowly via an IV pump.
Rationale: IV push potassium is extremely dangerous and can cause
fatal cardiac arrhythmias. Potassium must always be diluted and
administered as a slow infusion, typically via an IV pump, over
several hours.
Question 6
A nurse is assessing a client with a suspected ruptured abdominal aortic
aneurysm (AAA). What is a classic sign of a ruptured AAA?
A) Bradycardia and hypertension.
B) Sudden, severe, tearing abdominal or back pain with signs of hypovolemic
shock.
C) Mild, intermittent abdominal discomfort.
D) Localized redness and swelling in the abdomen.
E) Peripheral edema in the lower extremities.
Correct Answer: B) Sudden, severe, tearing abdominal or back pain
with signs of hypovolemic shock.
Rationale: Ruptured AAA is a life-threatening emergency presenting
with excruciating pain (abdominal, back, or flank), often radiating,
, accompanied by rapid signs of hypovolemic shock (hypotension,
tachycardia, pallor).
Question 7
A nurse is caring for a client prescribed warfarin. Which food should the
nurse advise the client to maintain a consistent intake of?
A) Citrus fruits.
B) Leafy green vegetables.
C) Dairy products.
D) Red meat.
E) Processed foods.
Correct Answer: B) Leafy green vegetables.
Rationale: Leafy green vegetables are high in Vitamin K, which can
reverse the effects of warfarin. Clients taking warfarin should
maintain a consistent intake of Vitamin K-rich foods rather than
avoiding them, to prevent fluctuations in INR.
Question 8
A client with Type 1 Diabetes Mellitus (T1DM) is exhibiting symptoms of
hypoglycemia. The client is conscious but disoriented. What is the nurse's
immediate action?
A) Administer a rapid-acting insulin.
B) Administer 15 grams of a simple carbohydrate orally.
C) Administer intravenous 50% dextrose (D50W).
D) Give intramuscular glucagon.
E) Offer a complex carbohydrate meal.
Correct Answer: B) Administer 15 grams of a simple carbohydrate
orally.
Rationale: For a conscious (even if disoriented) patient with
hypoglycemia, oral glucose (15-20g of a fast-acting carbohydrate
like juice or glucose tablets) is the safest and most appropriate
LATEST QUESTIONS WITH CORRECT DETAILED ANSWERS
WITH RATIONALES
Question 1
A nurse is caring for a client who is 2 days postoperative following an
abdominal colectomy. The client reports severe abdominal pain. Which non-
pharmacological intervention should the nurse prioritize to manage the pain?
A) Distraction with television.
B) Applying a cold compress to the abdomen.
C) Repositioning the client and ensuring proper body alignment.
D) Encouraging deep breathing exercises.
E) Providing aromatherapy.
Correct Answer: C) Repositioning the client and ensuring proper
body alignment.
Rationale: While all listed options (except cold compress for
abdominal pain) are non-pharmacological pain interventions,
repositioning and ensuring proper body alignment can directly
alleviate pressure on the surgical site and reduce muscular tension,
often providing significant immediate relief.
Question 2
A nurse is assessing a client with fluid volume deficit. Which of the following
findings would the nurse expect?
A) Bounding peripheral pulses.
B) Peripheral edema.
C) Dry mucous membranes and orthostatic hypotension.
D) Increased urine output.
E) Bradycardia.
Correct Answer: C) Dry mucous membranes and orthostatic
hypotension.
Rationale: Fluid volume deficit (dehydration) leads to decreased
circulating volume, resulting in dry mucous membranes, decreased
,skin turgor, orthostatic hypotension, tachycardia, and concentrated
urine with decreased output.
Question 3
A nurse is providing discharge teaching to a client with chronic obstructive
pulmonary disease (COPD). Which statement indicates the client
understands their oxygen therapy?
A) "I should increase my oxygen to 6 L/min if I feel short of breath."
B) "I will avoid using my oxygen unless I am very active."
C) "I should keep my oxygen flow rate as prescribed, usually 2-4 L/min via
nasal cannula, to avoid respiratory depression."
D) "It's okay to smoke while using my oxygen, as long as I'm careful."
E) "I only need my oxygen at night."
Correct Answer: C) "I should keep my oxygen flow rate as
prescribed, usually 2-4 L/min via nasal cannula, to avoid respiratory
depression."
Rationale: Clients with COPD may have a hypoxic drive to breathe.
High flow rates of oxygen can suppress this drive, leading to
hypoventilation and CO2 retention. Therefore, oxygen should be
used cautiously and at prescribed low flow rates.
Question 4
A nurse is caring for a client with hyperkalemia. Which ECG change would
the nurse anticipate?
A) Flattened T waves.
B) Prominent U waves.
C) Peaked T waves.
D) Shortened PR interval.
E) ST segment depression.
Correct Answer: C) Peaked T waves.
Rationale: Peaked, narrow T waves are a classic and often early ECG
,manifestation of hyperkalemia, indicating increased myocardial
irritability.
Question 5
A nurse is preparing to administer intravenous potassium chloride (KCl) to a
client. Which safety guideline is paramount for IV KCl administration?
A) Administer as an IV push for rapid correction.
B) Administer rapidly over 5 minutes.
C) Administer undiluted through a peripheral IV.
D) Never administer via IV push; always dilute and infuse slowly via an IV
pump.
E) Administer only through a central venous catheter.
Correct Answer: D) Never administer via IV push; always dilute and
infuse slowly via an IV pump.
Rationale: IV push potassium is extremely dangerous and can cause
fatal cardiac arrhythmias. Potassium must always be diluted and
administered as a slow infusion, typically via an IV pump, over
several hours.
Question 6
A nurse is assessing a client with a suspected ruptured abdominal aortic
aneurysm (AAA). What is a classic sign of a ruptured AAA?
A) Bradycardia and hypertension.
B) Sudden, severe, tearing abdominal or back pain with signs of hypovolemic
shock.
C) Mild, intermittent abdominal discomfort.
D) Localized redness and swelling in the abdomen.
E) Peripheral edema in the lower extremities.
Correct Answer: B) Sudden, severe, tearing abdominal or back pain
with signs of hypovolemic shock.
Rationale: Ruptured AAA is a life-threatening emergency presenting
with excruciating pain (abdominal, back, or flank), often radiating,
, accompanied by rapid signs of hypovolemic shock (hypotension,
tachycardia, pallor).
Question 7
A nurse is caring for a client prescribed warfarin. Which food should the
nurse advise the client to maintain a consistent intake of?
A) Citrus fruits.
B) Leafy green vegetables.
C) Dairy products.
D) Red meat.
E) Processed foods.
Correct Answer: B) Leafy green vegetables.
Rationale: Leafy green vegetables are high in Vitamin K, which can
reverse the effects of warfarin. Clients taking warfarin should
maintain a consistent intake of Vitamin K-rich foods rather than
avoiding them, to prevent fluctuations in INR.
Question 8
A client with Type 1 Diabetes Mellitus (T1DM) is exhibiting symptoms of
hypoglycemia. The client is conscious but disoriented. What is the nurse's
immediate action?
A) Administer a rapid-acting insulin.
B) Administer 15 grams of a simple carbohydrate orally.
C) Administer intravenous 50% dextrose (D50W).
D) Give intramuscular glucagon.
E) Offer a complex carbohydrate meal.
Correct Answer: B) Administer 15 grams of a simple carbohydrate
orally.
Rationale: For a conscious (even if disoriented) patient with
hypoglycemia, oral glucose (15-20g of a fast-acting carbohydrate
like juice or glucose tablets) is the safest and most appropriate
