ATI MED SURG PROCTORED EXAM RETAKE 2025
ACTUAL EXAM QUESTIONS & VERIFIED
ANSWERS/A+ GRADE
1. A client with heart failure reports sudden weight gain of 3 kg in 48 hours and
increasing shortness of breath. Which action should the nurse take first?
A. Encourage sodium-restricted diet.
B. Auscultate lung sounds and assess oxygenation.
C. Teach about daily weights.
D. Schedule an appointment with HCP next week.
Answer: B
Rationale: Acute weight gain + dyspnea suggests fluid overload and pulmonary
edema risk — assess lungs and oxygenation immediately before education or
scheduling.
2. A postop client received morphine 30 minutes ago and now has respiratory rate
8/min and pinpoint pupils. Which is the immediate nursing action?
A. Administer naloxone per protocol.
B. Encourage deep breathing.
C. Give promotional teaching about opioid effects.
D. Offer oral fluids.
Answer: A
Rationale: RR 8 with miosis indicates opioid overdose — naloxone is indicated
promptly to reverse respiratory depression.
3. A client with chronic COPD has SpO₂ 88% on room air but is alert and speaking
in full sentences. Which O₂ delivery is best to start?
A. Non-rebreather mask at 15 L/min.
B. Nasal cannula at 1–2 L/min.
C. CPAP immediately.
D. High-flow humidified oxygen at 50%.
Answer: B
Rationale: COPD patients are sensitive to high O₂; start low-flow (1–2 L) to
correct hypoxemia while avoiding suppression of hypoxic drive; monitor closely.
4. A client with DKA is admitted with blood glucose 520 mg/dL and K⁺ 5.6 mEq/L.
The nurse starts IV insulin infusion. Which electrolyte change must be
anticipated?
A. Serum potassium will decrease — monitor and be ready to replace K⁺.
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, B. Serum potassium will increase — hold K⁺ replacement.
C. Sodium will fall immediately — give hypertonic saline.
D. Magnesium will rise — no action needed.
Answer: A
Rationale: Insulin drives K⁺ into cells causing hypokalemia; anticipate drop and
monitor K⁺, replacing as needed.
5. A client on warfarin (coumadin) has INR 6.2 and is stable without bleeding. What
should the nurse anticipate?
A. Hold warfarin and give vitamin K per HCP order.
B. Continue current dose; recheck in 2 weeks.
C. Give fresh frozen plasma immediately.
D. Start heparin infusion.
Answer: A
Rationale: INR >5–9 without bleeding typically requires holding warfarin and
administering vitamin K to reduce bleeding risk; FFP reserved for serious
bleeding.
6. A client with an acute ischemic stroke arrives within the window for tPA. Which
finding is a contraindication to tPA?
A. BP 160/90 mmHg.
B. Platelet count 80,000/mm³.
C. Onset of symptoms 60 minutes ago.
D. No anticoagulant use.
Answer: B
Rationale: Thrombocytopenia (platelets <100,000) is a contraindication due to
bleeding risk. BP 160/90 may be manageable; timing is acceptable.
7. Post-op day 1 after abdominal surgery, a client has a temperature of 38.5°C,
wound erythema, and purulent drainage. What’s the priority?
A. Obtain wound culture and start antibiotics as ordered.
B. Apply additional dressings only.
C. Document and recheck in 8 hours.
D. Encourage increased mobility.
Answer: A
Rationale: Signs of surgical site infection require culture and initiation of
antibiotics per HCP; timely treatment prevents spread.
8. A client with MI develops acute pulmonary edema. Which assessment finding is
most consistent?
A. Pink frothy sputum and crackles throughout lung fields.
B. Clear lung sounds and bradycardia.
C. Abdominal distension only.
D. Warm dry skin.
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, Answer: A
Rationale: Pulmonary edema produces pink frothy sputum and diffuse crackles
due to fluid in alveoli.
9. A nurse is administering potassium chloride IV to a hypokalemic client. Which
action is essential?
A. Administer via infusion pump and monitor cardiac rhythm.
B. Give IV push for rapid correction.
C. Mix with dextrose to hasten uptake.
D. Infuse only into hand veins.
Answer: A
Rationale: IV KCl must be given via pump, diluted, at safe rate, with cardiac
monitoring to prevent arrhythmias.
10. A client reports calf pain with swelling and a positive Homan’s sign. What is the
safest immediate intervention?
A. Apply compression stockings and keep client mobile.
B. Obtain Doppler ultrasound and start anticoagulation per protocol.
C. Massage the calf to relieve pain.
D. Encourage long walks to reduce clotting.
Answer: B
Rationale: Suspected DVT requires diagnostic ultrasound and anticoagulation;
do not massage (risk embolization).
11. A client with pneumonia is on IV ceftriaxone. They develop watery diarrhea and
abdominal cramping. What should nurse do first?
A. Assess for C. difficile and notify HCP; obtain stool sample.
B. Stop antibiotic immediately without consulting.
C. Continue antibiotic and give antidiarrheal.
D. Start probiotics and discharge.
Answer: A
Rationale: Antibiotic-associated diarrhea can indicate C. difficile — assess, test,
notify provider; antidiarrheals contraindicated until assessed.
12. A postoperative client with a femur fracture complains of sudden chest pain and
shortness of breath. Vitals: tachycardia, hypoxia. What is most likely and
immediate action?
A. Suspect pulmonary embolism; call rapid response, administer O₂, prepare for
anticoagulation per protocol.
B. Give oral aspirin and observe.
C. Encourage coughing and deep breathing only.
D. Apply heat to the chest.
Answer: A
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ACTUAL EXAM QUESTIONS & VERIFIED
ANSWERS/A+ GRADE
1. A client with heart failure reports sudden weight gain of 3 kg in 48 hours and
increasing shortness of breath. Which action should the nurse take first?
A. Encourage sodium-restricted diet.
B. Auscultate lung sounds and assess oxygenation.
C. Teach about daily weights.
D. Schedule an appointment with HCP next week.
Answer: B
Rationale: Acute weight gain + dyspnea suggests fluid overload and pulmonary
edema risk — assess lungs and oxygenation immediately before education or
scheduling.
2. A postop client received morphine 30 minutes ago and now has respiratory rate
8/min and pinpoint pupils. Which is the immediate nursing action?
A. Administer naloxone per protocol.
B. Encourage deep breathing.
C. Give promotional teaching about opioid effects.
D. Offer oral fluids.
Answer: A
Rationale: RR 8 with miosis indicates opioid overdose — naloxone is indicated
promptly to reverse respiratory depression.
3. A client with chronic COPD has SpO₂ 88% on room air but is alert and speaking
in full sentences. Which O₂ delivery is best to start?
A. Non-rebreather mask at 15 L/min.
B. Nasal cannula at 1–2 L/min.
C. CPAP immediately.
D. High-flow humidified oxygen at 50%.
Answer: B
Rationale: COPD patients are sensitive to high O₂; start low-flow (1–2 L) to
correct hypoxemia while avoiding suppression of hypoxic drive; monitor closely.
4. A client with DKA is admitted with blood glucose 520 mg/dL and K⁺ 5.6 mEq/L.
The nurse starts IV insulin infusion. Which electrolyte change must be
anticipated?
A. Serum potassium will decrease — monitor and be ready to replace K⁺.
-1-
, B. Serum potassium will increase — hold K⁺ replacement.
C. Sodium will fall immediately — give hypertonic saline.
D. Magnesium will rise — no action needed.
Answer: A
Rationale: Insulin drives K⁺ into cells causing hypokalemia; anticipate drop and
monitor K⁺, replacing as needed.
5. A client on warfarin (coumadin) has INR 6.2 and is stable without bleeding. What
should the nurse anticipate?
A. Hold warfarin and give vitamin K per HCP order.
B. Continue current dose; recheck in 2 weeks.
C. Give fresh frozen plasma immediately.
D. Start heparin infusion.
Answer: A
Rationale: INR >5–9 without bleeding typically requires holding warfarin and
administering vitamin K to reduce bleeding risk; FFP reserved for serious
bleeding.
6. A client with an acute ischemic stroke arrives within the window for tPA. Which
finding is a contraindication to tPA?
A. BP 160/90 mmHg.
B. Platelet count 80,000/mm³.
C. Onset of symptoms 60 minutes ago.
D. No anticoagulant use.
Answer: B
Rationale: Thrombocytopenia (platelets <100,000) is a contraindication due to
bleeding risk. BP 160/90 may be manageable; timing is acceptable.
7. Post-op day 1 after abdominal surgery, a client has a temperature of 38.5°C,
wound erythema, and purulent drainage. What’s the priority?
A. Obtain wound culture and start antibiotics as ordered.
B. Apply additional dressings only.
C. Document and recheck in 8 hours.
D. Encourage increased mobility.
Answer: A
Rationale: Signs of surgical site infection require culture and initiation of
antibiotics per HCP; timely treatment prevents spread.
8. A client with MI develops acute pulmonary edema. Which assessment finding is
most consistent?
A. Pink frothy sputum and crackles throughout lung fields.
B. Clear lung sounds and bradycardia.
C. Abdominal distension only.
D. Warm dry skin.
-2-
, Answer: A
Rationale: Pulmonary edema produces pink frothy sputum and diffuse crackles
due to fluid in alveoli.
9. A nurse is administering potassium chloride IV to a hypokalemic client. Which
action is essential?
A. Administer via infusion pump and monitor cardiac rhythm.
B. Give IV push for rapid correction.
C. Mix with dextrose to hasten uptake.
D. Infuse only into hand veins.
Answer: A
Rationale: IV KCl must be given via pump, diluted, at safe rate, with cardiac
monitoring to prevent arrhythmias.
10. A client reports calf pain with swelling and a positive Homan’s sign. What is the
safest immediate intervention?
A. Apply compression stockings and keep client mobile.
B. Obtain Doppler ultrasound and start anticoagulation per protocol.
C. Massage the calf to relieve pain.
D. Encourage long walks to reduce clotting.
Answer: B
Rationale: Suspected DVT requires diagnostic ultrasound and anticoagulation;
do not massage (risk embolization).
11. A client with pneumonia is on IV ceftriaxone. They develop watery diarrhea and
abdominal cramping. What should nurse do first?
A. Assess for C. difficile and notify HCP; obtain stool sample.
B. Stop antibiotic immediately without consulting.
C. Continue antibiotic and give antidiarrheal.
D. Start probiotics and discharge.
Answer: A
Rationale: Antibiotic-associated diarrhea can indicate C. difficile — assess, test,
notify provider; antidiarrheals contraindicated until assessed.
12. A postoperative client with a femur fracture complains of sudden chest pain and
shortness of breath. Vitals: tachycardia, hypoxia. What is most likely and
immediate action?
A. Suspect pulmonary embolism; call rapid response, administer O₂, prepare for
anticoagulation per protocol.
B. Give oral aspirin and observe.
C. Encourage coughing and deep breathing only.
D. Apply heat to the chest.
Answer: A
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