ATI RN ADULT MEDICAL SURGICAL ACTUAL EXAM
QUESTIONS WITH VERIFIED ANSWERS 2025
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the f
ollowing 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 thrombo
embolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-
chest drainage system. Which of the followingRfindings 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 lungRre-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. W
hich 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 p
ulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be moni
tored 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 target
ed therapeutic range of 2 to 3 for a client who has atrial fibrillation.
ARhome health nurse is providing teaching to a clientRwho has a stage 1 pressure injury on the greater tr
ochanter 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 decreasesRpressure 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 experien
cing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes fr
om the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vo
miting, fatigue, and headache.
,A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is una
ble 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. Scanni
ng 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 comm
unity 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 tha
t the disorder with the greatest risk for this group of clients is hypertension. The prevalence of hyperten
sion is highest among African American clients, followed by Caucasian clients, and then Hispanic clients.
ARnurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse t
hat 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.
ARnurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of the foll
owing findings should the nurse report to the provider immediately? - CORRECT ANSWER -Stridor
Rationale: Using the urgentRvs. 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 ede
ma or laryngeal spasms. The nurse should report the finding immediately and implement an interventio
n.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the following fi
ndings 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 th
e nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission precaution
s should the nurse initiate? - CORRECT ANSWER -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, v
aricella, 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? - CORRECT ANSWER -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 followingRfindi
ngs is the nurse's priority? - CORRECT ANSWER -Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine th
at the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessi
ve thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should re
port this finding immediately to the provider because it can lead to seizures and coma.
ARnurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of th
e following statements by the client indicates understanding of the teaching? - CORRECT ANSWER -
"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, whi
ch could create the opportunity for infection.
ARnurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Wh
ich of the followingRinformation should the nurse include in the teaching? - CORRECT ANSWER -
"Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of verapamil. The cli
ent 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 instructi
ons should the nurse include? - CORRECT ANSWER -Walk for 30 min four times per week.
Rationale: Weight-
bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.
ARnurse is providing teaching to a client who is perimenopausal and has a prescription for hormone repl
acement therapy. For which of the following? - CORRECT ANSWER -Calf pain
Numbness in the arm
QUESTIONS WITH VERIFIED ANSWERS 2025
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the f
ollowing 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 thrombo
embolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-
chest drainage system. Which of the followingRfindings 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 lungRre-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. W
hich 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 p
ulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be moni
tored 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 target
ed therapeutic range of 2 to 3 for a client who has atrial fibrillation.
ARhome health nurse is providing teaching to a clientRwho has a stage 1 pressure injury on the greater tr
ochanter 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 decreasesRpressure 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 experien
cing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes fr
om the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vo
miting, fatigue, and headache.
,A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is una
ble 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. Scanni
ng 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 comm
unity 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 tha
t the disorder with the greatest risk for this group of clients is hypertension. The prevalence of hyperten
sion is highest among African American clients, followed by Caucasian clients, and then Hispanic clients.
ARnurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse t
hat 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.
ARnurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of the foll
owing findings should the nurse report to the provider immediately? - CORRECT ANSWER -Stridor
Rationale: Using the urgentRvs. 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 ede
ma or laryngeal spasms. The nurse should report the finding immediately and implement an interventio
n.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the following fi
ndings 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 th
e nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission precaution
s should the nurse initiate? - CORRECT ANSWER -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, v
aricella, 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? - CORRECT ANSWER -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 followingRfindi
ngs is the nurse's priority? - CORRECT ANSWER -Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine th
at the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessi
ve thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should re
port this finding immediately to the provider because it can lead to seizures and coma.
ARnurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of th
e following statements by the client indicates understanding of the teaching? - CORRECT ANSWER -
"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, whi
ch could create the opportunity for infection.
ARnurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Wh
ich of the followingRinformation should the nurse include in the teaching? - CORRECT ANSWER -
"Increase fiber intake to avoid constipation."
Rationale: The nurse should instruct the client that constipation is an adverse effect of verapamil. The cli
ent 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 instructi
ons should the nurse include? - CORRECT ANSWER -Walk for 30 min four times per week.
Rationale: Weight-
bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.
ARnurse is providing teaching to a client who is perimenopausal and has a prescription for hormone repl
acement therapy. For which of the following? - CORRECT ANSWER -Calf pain
Numbness in the arm
