ATI RN MEDSURG 2023/2024 PROCTORED EXAM- LATEST 100%
CORRECT STUDY GUIDE.Q$A WITH RATIONALES
1. A nurse is assessing a patient who is 12hr postoperative following a colon resection. Which of
the following findings should the nurse report to the surgeon?
A. Heart rate 90/min
B. Absent bowel sounds
normal findings after major bowel surgery; takes several days to
return to normal.
C. Hgb 8.2 g/dl
D. Gastric pH of 3.0
Answer: C. Hgb 8.2 g/dl
Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.
2. A nurse is caring for a patient who has diabetes insipidus. Which of the following medications
should the nurse plan to administer?
A. Desmopressin
B. Regular insulin
C. Furosemide
D. Lithium carbonate
Answer: A. Desmopressin
Rationale: Diabetes Insipidus has decreased ADH. Administer Desmopressin/Vasopressin
increase ADH and keeps pt. on urinating
3. A nurse is admitting a patient who has arthritic pain and reports taking ibuprofen several times
daily for 3 years. Which of the following test should the nurse monitor?
A. Fasting blood glucose
B. Stool for occult blood
C. Urine for white blood cells
D. Serum calcium
Answer: B. Stool for occult blood
Rationale: ATI Pharm 16. Pg. 485 Ibuprofen (NSAIDs) monitor for GI bleed (bloody, tarry
stools, abd pain).
4. A nurse in the emergency department is assessing a patient. Which of the following actions
should the nurse take first (Click on the “Exhibit” button for additional information about the
patient. There are three tabs that contain separate categories of data.)
A. Obtain a sputum sample for culture
B. Prepare the patient for a chest x-ray
C. Initiate airborne precautions
D. Administer ondansertron.
Answer: C. Initiate airborne precautions
Rationale: No idea what the Exhibit is all about; wont be able to answer it.
5. A nurse is contacting the provider for a patient who has cancer and is experiencing break
through pain. Which of the following prescriptions should the nurse anticipate?
A. Transmucosal fentanyl
B. Intramuscular meperidine
C. Oral acetaminophen
D. Intravenous dexamethasone
Answer: A. Transmucosal fentanyl
6. A nurse is admitting a patient who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the patient is
experiencing a myocardial infarction?
A. PR interval
B. QRS duration
C. T wave
D. ST segment
Answer: D. ST segment
Rationale: ST elevation indicates MI. ST depression indicates ischemia
7. A nurse is teaching a patient who has ovarian cancer about skin care following radiation
treatment. Which of the following instructions should the nurse include?
A. Pat the skin on the radiation site to dry it
B. Apply OTC moisturizer to the radiation site
C. Cover the radiation site loosely with a gauze wrap before dressing
D. Use a soft washcloth to clean the area around the radiation site
Answer: A. Pat the skin on the radiation site to dry it
Rationale: pg. 584. Dry the area thoroughly using patting motions.
8. A nurse is caring for a patient who is receiving a blood transfusion. The nurse observes that the
patient has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse
should anticipate administering which of the following prescribed medications?
A. Diphenhydramine
B. Acetaminophen
C. Pantoprazole
D. Furosemide
Answer: D. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics
to prevent cardiovascular/respiratory distress.
9. A nurse is assessing a patient who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the medication?
A. Lungs clear
B. Apical pulse 82/min
C. Hyperactive bowel sounds
D. Blood pressure 90/50 mm Hg
Answer: B. Apical pulse 82/min
Rationale: ATI p. 494: s/s of hypomagnesemia consist of hypoactive bowel sounds, constipation,
paralytic ileus. So effectiveness would indicate opposite of this
10. A nurse is reviewing a patient’s ABG results pH 7.42, PaCO2 30 mm Hg, and HCO3 21
mEq/L. The nurse should recognize these findings as indication of which of the following
conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Answer: C. Compensated respiratory alkalosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis
11. A nurse is caring for a patient who has a deep partial thickness burns over 15% of her body
which of the following labs should the nurse expect during the first 24 hours
A. Decreased BUN ELEVATED DT fluid loss
B. Hypoglycemia (High due to stress)
C. Hypoalbuminemia (Low due to fluid loss)
D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)
Answer: C. Hypoalbuminemia (Low due to fluid loss)
12. A nurse is caring for a patient who has dumping syndrome following a gastrectomy, which of
the following actions should the nurse take?
A. Offer the patient high carbohydrate meal options (High fat, high protein, low fiber, low to
moderate carbs page 317, chapter 49 Peptic ulcer disease med surge ati pdf 10.0)
B. Provide the patient with four full meals a day (Small frequent meals)
C. Encourage the patient to drink at least 360 ml of fluids with meals (Eliminate liquids with
meals for 1 hr prior and following a meal)
D. Have the patient lie down for 30 minutes after meals (Lying down after a meal slows the
movement of food within the intestines)
Answer: D. Have the patient lie down for 30 minutes after meals (Lying down after a meal slows
the movement of food within the intestines)
13. A nurse is teaching a group of young adult patients about risk factors for hearing loss. Which
of the following factors should the nurse include in the teaching? SATA.
A. Born with a high weight
B. Chronic infections of the middle ear
C. Use a loop diuretic
D. Perforation of the ear drum
E. Frequent exposure to low volume noise
Answer: B. Chronic infections of the middle ear
C. Use a loop diuretic
D. Perforation of the ear drum
14. A nurse is preparing to administer fresh frozen plasma to a patient. Which of the following
actions should the nurse take?
A. Administer the plasma immediately after thawing (Blood must be warm, you also have a 30
minute window to give it so bacteria doesn’t grow. So it doesn’t necessarily have to be right
away.)
B. Transfuse the plasma over 4 hour (Can be in 2 to 4 hours)
C. Hold the transfusion if the patient is actively bleeding (YOU HAVE TO GIVE IT. That’s the
whole point! The patient is losing blood so you have to replace it. We give fresh frozen plasma
because he or she may have clotting deficiencies)
D. Administer the transfusion through a 24 gauge saline lock (Has to be a 18 or 20 gauge)
Answer: B. Transfuse the plasma over 4 hour (Can be in 2 to 4 hours)
15. A nurse is assessing a patients who reports numbness and tingling of his toes and exhibits a
positive TROUSSEAU. Which of the following electrolyte imbalance should the nurse suspect?
A. Hypoatremia
B. Hyperchloremia
C. Hypermagnesemia
D. Hypocalcemia (low calcium = low ca causes increased firing = spasms. Learned this is LVN
school.)
Answer: D. Hypocalcemia (low calcium = low ca causes increased firing = spasms. Learned this
is LVN school.)
16. A home health nurse is teaching a patients how to care for a peripherally central catheter in
his right arm. Which of the following statements should the nurse include in the teaching?
A. Change the transparent dressing over the insertion site every 7 days or if it becomes wet,
soiled, or loose.
B. Clean the insertion site with mild soap and water, and cover the site during showering to
prevent water from entering.
C. Use a 10 millilitre syringe when flushing the catheter - flush with 10 ml NS b4 and after med
administration
D. Avoid using a smaller syringe (e.g., 3 mL or 5 mL) for flushing.
Answer: C. Use a 10 millilitre syringe when flushing the catheter - flush with 10 ml NS b4 and
after med administration
17. A nurse is caring for a patient who has a central venous access device. Which of the
following assessment findings should the nurse report to the provider?
A. RBC count of 4.7 million/mm3
B. BUN 22 mg/ dl - not dramatically high enough to pay attention to.
C. WBC count of 16,000/ mm3 - phlebitis is a complication , infection is a complication that can
happen 7days after insertion , also temp increase if 1 degree can happen.
D. Blood glucose of 120 mg/dl
Answer: C. WBC count of 16,000/ mm3 - phlebitis is a complication , infection is a complication
that can happen 7days after insertion , also temp increase if 1 degree can happen.
18. A nurse is providing dietary teaching to a patient who has chronic kidney disease and a
decreased glomerular filtration rate. Which of the following statements by the patient indicates
an understanding of the teaching?
A. I will spread my protein allowances over the entire day - the doctor issue the patient an
allowed amount of protein so its ok.
B. I should increase my intake of canned salmon to three times per week (NO SODIUM)
C. I will season my food with lemon pepper rather than salt (We do not want to give the dietary
sodium, potassium, phosphorus , and magnesium.
D. I don’t know what lemon pepper has, but we want to RESTRICT sodium, potassium,
phosphorus and magnesium.)
E. I should limit my intake of hard cheese to 3 ounces each day (NO SODIUM at all)
Answer: A. I will spread my protein allowances over the entire day - the doctor issue the patient
an allowed amount of protein so its ok.
19. A nurse is caring for a patient who has a peripherally inserted central catheter. The patient is
receiving an antibioticvia intermittent IV bolus. Which of the following actions should the nurse
take?
A. Administer 20 ml of 0.9 sodium chloride after each dose of medication (you only flush with
10 ml of NS, not 20 is for flushing blood)
B. Flush the catheter using a 5 ml syringe - you use a 10mL syringe to flush
C. Verify the placement with an x ray prior to the initial dose
D. Change the transparent membranes dressing daily (dressing can last for up to 7 days)
Answer: C. Verify the placement with an x ray prior to the initial dose
20. A nurse is teaching a patient using a metered dose rescue inhaler. Which of the following
statements should the nurse include in the teaching?
A. Do not shake your inhaler before use (suppose to shake it)
B. Exhale fully before bringing the inhaler to your lips
C. Depress the canister after you inhale (depress the canister before inhaling, and 5 seconds later
you inhale)
D. Use peroxide to clean the mouthpiece if your inhaler (warm water)
Answer: B. Exhale fully before bringing the inhaler to your lips
21. A nurse is assessing the pain status of a group of patients. Which of the following findings
indicate a patient is experiencing referred pain? (page 30)
A. A patient who has angina reports substernal chest pain
B. A patient who has pancreatitis reports pain in the left shoulder
C. A patient who is postoperative reports incisional pain
D. A patient who has peritonitis reports generalized abdominal pain
Answer: B. A patient who has pancreatitis reports pain in the left shoulder
22. A nurse is caring for a patient who has just returned from surgery with an external fixator to
the left tibia. Which of the following assessments findings requires immediate intervention by
the nurse?
A. The patient reports a pain level of 7 on a scale from 0 -10 at the operative site. (This foo just
came from surgery so pain is normal for post op patients for first couple of hours.)
B. The patients capillary refill in the left toe is 6 seconds sxs of compartment syndrome. ABCs
are compromised. (Cap refill should be below 3 seconds. This is sxs for compartment syndrome.
Untreated can lead to necrosis.)
C. The patient has an oral temperature of 38.3 (100.9 F) (I wouldn’t pick this because i always
see temp 101 as a priority from previous rationales with other atis.)
D. The patient has 100 ml of blood in the closed suction drained. (I believe this is normal for
post-op patients.)
Answer: B. The patients capillary refill in the left toe is 6 seconds sxs of compartment
syndrome. ABCs are compromised. (Cap refill should be below 3 seconds. This is sxs for
compartment syndrome. Untreated can lead to necrosis.)
23. A nurse is assessing a patient who has acute pancreatitis and has been receiving total
parenteral nutrition for the past 72 hours. Which of the following findings requires the nurse to
intervene?
A. Right upper quadrant pain (Dude has acute pancreatitis, so it’s normal)
B. Capillary blood glucose level of 164 mg/dl - glucose not significantly high
C. WBC count 13,000/mm3 (Infection is one complication of TPN administration but WBC is in
normal range.)
D. Crackle in bilateral lower lobes (ABC’s compromised, also one of the complications of TPN
is fluid imbalance aka fluid volume excess.)
Answer: D. Crackle in bilateral lower lobes (ABC’s compromised, also one of the complications
of TPN is fluid imbalance aka fluid volume excess.)
24. A nurse is caring for a patient who has hypotension, cool and clammy skin, tachycardia, and
tachypnea. In which of the following positions should the nurse place the patient?
A. Reverse Trendelenburg
B. Side Lying High Fowler's
C. Feet Elevated
Answer: C. Feet Elevated
25. A nurse is caring for a patient who has tuberculosis and is taking rifampin. The patient reports
that her saliva has turned red-orange in color. Which of the following responses should the nurse
make?
A. “This finding may indicate possible medication toxicity”
B. “Your provider will prescribe a different medication regimen”
C. “This is an expected adverse effect of this medication”
D. “You will need to increase your fluid intake to resolve this problem”
Answer: C. “This is an expected adverse effect of this medication”
26. A nurse is preparing to administer a unit of packed RBCs for a patient who is receiving a
continuous IV infusion of 5% dextrose in water. Which of the following actions should the nurse
take?
A. Administer the unit through secondary IV tubing
B. Verify the blood product with an assistive personnel
C. Begin an IV infusion of 0.9% sodium chloride
D. Insert another 22-gauge IV catheter
Answer: C. Begin an IV infusion of 0.9% sodium chloride
27. A nurse is planning care for a patient who is 12 hr postoperative following a kidney
transplant. Which of the following actions should the nurse include in the plan of care?
A. Check the patient’s blood pressure every 8 hr
B. Administer opioids PO
C. Assess urine output hourly
D. Monitor for hypokalemia as a manifestation of acute rejection
Answer: C. Assess urine output hourly
28. A nurse in an emergency department is assessing a patient who has cirrhosis of the liver.
Which of the following is a priority finding?
A. Yellow sclera (Normal)
B. Mental confusion can lead to portal systemic encephalopathy
C. Palmar erythema (Normal)
D. Spider angiomas (Normal)
Answer: B. Mental confusion can lead to portal systemic encephalopathy
29. A nurse is obtaining a medication history from a patient who is to start therapy with naproxen
for rheumatoid arthritis. Which of the following medications places the patient at risk for
bleeding?
A. Captopril
B. Ibuprofen
C. Digoxin
D. Phenytoin
Answer: B. Ibuprofen
30. A nurse is caring for a patient in diabetic ketoacidosis (DKA). Which of the following is the
priority intervention by the nurse?
A. Administer 0.9% sodium chloride
B. Check potassium levels
C. Initiate a continuous IV insulin infusion
D. Begin bicarbonate continuous IV infusion
Answer: C. Initiate a continuous IV insulin infusion
31. A nurse is assessing the extremities of a patient who has Raynaud’s disease. Which of the
following findings should the nurse expect?
A. Blanching of the hands
B. Hyperactive reflexes
C. Calf pain with foot dorsiflexion
D. Vitiligo on affected extremities
Answer: A. Blanching of the hands
32. A nurse is caring for a group of patients. The nurse should obtain a blood pressure reading
using only the left extremity from which of the following patients?
A. A patient who has a peripherally inserted central catheter in the left arm
B. A patient who has left-sided Bell’s palsy
C. A patient who has a right upper extremity arteriovenous fistula
D. A patient who has right-sided weakness due to Parkinson’s disease
Answer: C. A patient who has a right upper extremity arteriovenous fistula
33. A nurse is providing teaching to a patient who has DVT. Which of the following findings
should the nurse identify as a risk factor for the development of DVTs?
A. Hypertension
B. Cirrhosis
C. NSAIDS use
D. Oral Contraceptive
Answer: D. Oral Contraceptive
34. A nurse is caring for patient who has Cushing’s disease. Which of the following actions
should the nurse take first? (Click Exhibit button for additional information)
A. Check the patient’s medication administration record for antihypertensive medication.
B. Verify the patient’s understanding of sodium restriction.
C. Auscultate the patient’s lung sound
D. Determine the need for further glucose monitoring.
Answer: D. Determine the need for further glucose monitoring.
Rationale: Unable to answer. Can’t see the exhibit. But on the chapter of Cushing disease they
talk about monitoring of glucose. The rest are not stated in the chapter.
35. A nurse is assessing a patient who has nephrotic syndrome. Which of the findings should the
nurse expect?
A. Proteinuria
B. Flank pain
C. Hyperalbuminemia
D. Hypotension
Answer: A. Proteinuria
Rationale: Lewis book page 1075. Clinical manifestation of N.S.: peripheral edema, massive
proteinuria, HTN, hyperlipidemia, and hypoalbuminemia.
36. A nurse is assessing a patient who has right-sided heart failure. Which of the following
assessment findings should the nurse expect to find?
A. Oliguria (Left)
B. S3/S4 galloping heart sounds (Left)
C. Poor skin turgor
D. Pitting edema
Answer: D. Pitting edema
37. A nurse is caring for a patient who has newly inserted chest tube. The nurse should clarify
which of the following prescriptions with the provider?
A. Notify the provider when tidaling ceases. (Yes notify)
B. Assisting the patient out of bed three times daily.
C. Vigorously strip the chest tube twice daily.
D. Administer morphine 2 mg IV bolus every 3 hr PRN for pain.
Answer: C. Vigorously strip the chest tube twice daily.
Rationale: Page 104 chapter 18 of ATI Book it says that: “Do not strip or milk tubing; only
perform when prescribed. Stripping creates a high negative pressure and can damage lung
tissue.”
38. A nurse is teaching a patient who is taking an ACE inhibitor for heart failure. Which of the
following instructions should the nurse include for home management of heart failure?
A. Obtain daily weight.
B. Use of salt substitute. (Avoid it)
C. Monitor I and O.
D. Limit daily activity.
Answer: C. Monitor I and O.
39. A nurse is providing discharge teaching to a patient who has a permanent pacemaker. Which
of the following statements by the patient indicates an understand of the teaching?
A. I need to maintain pressure over the pacemaker site with an elastic bandage.
B. I need to check my pulse rate every day for a full minute.
C. The pacemaker will deliver shock if I develop a dysrhythmia
D. When a microwave oven is in use, I need to stay out of the room.
Answer: B. I need to check my pulse rate every day for a full minute.
40. A nurse in a clinic is providing preventive teaching to an older adult patient during well visit.
The nurse should instruct the patient that which of the following immunization are recommended
for healthy adults after age 60? SATA.
A. Herpes Zoster
B. Influenza
C. HPV
D. Meningococcal
E. Pneumococcal Polysaccharide
Answer: A. Herpes Zoster
B. Influenza
E. Pneumococcal Polysaccharide
41. A nurse is assessing a patient who is 4hr postoperative following arterial revascularization of
the left femoral artery. Which of the following findings should the nurse report immediately?
A. Bruising around the incision site
B. Pallor in the affected extremity
C. Urine output 150mL over 4hr
D. Temperature of 37.9 (100.2)
Answer: B. Pallor in the affected extremity
42. A nurse is caring for an older adult patient who has not been eating. Which of the following
findings indicates dehydration?
A. Crackles auscultated bilaterally (S/sx suggestive of fluid overload)
B. Capillary refill of 2 seconds (Brisk; normal)
C. Dimiminished peripheral pulses
D. Engorged neck veins (Also fluid overload)
Answer: C. Dimiminished peripheral pulses
43. A nurse is preparing to discharge a patient who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions
with the provider?
A. Increase intake of fiber rich foods
B. May operate a motor vehicle when no longer taking analgesics
C. Take tub baths instead of showers
D. May place a small pillow under the head when sleeping
Answer: C. Take tub baths instead of showers
44. A nurse is assessing for elderly signs of compartment syndrome for a patient who has a short
leg fiberglass cast. Which of the following findings should the nurse expect?
A. Bounding distal pulses
B. Capillary refill less than 2 seconds (Pretty much the only thing that makes sense)
C. Erythema of the toes
D. Intense pain with movement
Answer: D. Intense pain with movement
45. A nurse is caring for a patient who is postoperative following coronary artery bypass surgery
and reports shortness of breath. The nurse administers oxygen at 3L/min and obtains arterial
blood gases 60 min later. Which of the following lab findings indicates a positive response to the
oxygen therapy?
A. PaCO2 34 mmHg
B. Bicarbonate 20 mEq/L
C. PaO2 90 mmHg (Normal range: 80-100 mmHg)
D. Ph 7.32
Answer: C. PaO2 90 mmHg (Normal range: 80-100 mmHg)
46. A nurse is performing a cranial nerve assessment on a patient following a head injury. Which
of the following findings should the nurse expect if the patient has impaired function of the
vestibulocochlear (VIII)?
A. Loss of peripheral vision (CN II, is in charge of this)
B. Disequilibrium with movement
C. Deviation of the tongue from midline (CN XII)
D. Inability to smell (CN I)
Answer: B. Disequilibrium with movement
47. A nurse is caring for a patient admitted with a skull fracture. Which of the following
assessment findings should be of greatest concern to the nurse?
A. Glasgow coma scale score changes from 14 to 9
B. Bilateral pupil diameter changes from 4 to 2 mm
C. Pulse pressure changes from 30 to 20 mm Hg
D.WBC count changes from 9000 to 16,000 mm3
Answer: A. Glasgow coma scale score changes from 14 to 9
48. A nurse is caring for a patient who is taking furosemide. The patient has a potassium level of
3.1 mEq/L. Which of the following should the nurse assess first?
A. Urine output
B. Level of orientation
C. Cardiovascular status (Potassium imbalances causes DYSRHYTHMIAS which is the number
one reason why potassium levels are crucial to monitor.)
D. Muscle weakness- this is an early sign of K imbalance but i would go with C since ABC’s are
always first.
Answer: C. Cardiovascular status (Potassium imbalances causes DYSRHYTHMIAS which is
the number one reason why potassium levels are crucial to monitor.)
49. A nurse is caring for a patient who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
A. Instruct the patient to take deep breaths and hold them during the procedure
B. Administer a stool softener following the procedure
C. Ask the patient to empty his bladder prior to the procedure
D Assist the patient into the left lateral position during the procedure- they must be upright with
feet supported.
Answer: C. Ask the patient to empty his bladder prior to the procedure
50. A nurse is caring for a patient who is 6 hours postoperatively following a thyroidectomy. The
patient reports tingling and numbness in the hands. The nurse should identify this as a sign of
which of following electrolytes imbalances?
A. Hypernatremia
B. Hypomagnesemia
C. Hypokalemia
D. Hypocalcemia (Parathyroid gland which is the gland that secretes calcitonin is right behind
the thyroid.
Answer: D. Hypocalcemia (Parathyroid gland which is the gland that secretes calcitonin is right
behind the thyroid.
When you have a thyroidectomy, you decrease the production of calcitonin which decreases
production of calcium.)
51. A nurse is assessing a patient 15 min after the start of a transfusion of 1 unit of packed
RBC’s. Which of the following findings is an indication of a hemolytic transfusion reaction?
A. Hypotension
B. Bradypnea-tachypnea ( RR > 20) it will produce
C. Bradycardia- tachycardia it will produce
D. Hypothermia - FEVER is a complication of a hemolytic reaction
Answer: A. Hypotension
52. A nurse in an emergency department is caring for a patient who has sinus bradycardia. Which
of the following actions should the nurse take first?
A. Prepare the patient for temporary pacing → too invasive
B. Initiate IV fluid therapy for the patient → to solve hypotension
C. Measure the patient’s blood pressure → related to hypotension
D. Administer atropine to the patient (Pg 638 Atropine Sulfate treats Bradycardia)
Answer: B. Initiate IV fluid therapy for the patient → to solve hypotension
53. A nurse is caring for a patient who has a prescription to discontinue a peripherally inserted
central catheter. Which of the following actions should the nurse take?
A. Apply slight pressure when resistance is met
B. Measure the catheter after removal
C. Remove the catheter with one continuous motion
D. Place a dry sterile dressing to the site after removal
Answer: D. Place a dry sterile dressing to the site after removal
54. A nurse is caring for a patient who has a flail chest. Which of the following actions should the
nurse take?
A. Provide humidified oxygen
B. Implement fluid restriction nope
C. Administer antibiotic medication
D. Administer acetaminophen orally nope
Answer: A. Provide humidified oxygen
55. A nurse is teaching a group of newly licensed nurses about acute respiratory failure. Which of
the following manifestations should the nurse include in the teaching?
A. Hypoxemia
B. Hyperventilation (Can’t be this because you are forsure going to have HYPERCARBIA and
>20 RR will excrete CO2.)
C. Hypocarbia- hypercarbia
D. Hypervolemia (You’re going to have hypotension during ARF. If you have too much fluid in
your body then you would have high blood pressure.)
Answer: A. Hypoxemia
56. A nurse is caring for a patient who is experiencing a seizure. Which of the following actions
should the nurse take first?
A. Obtain the patient’s vital signs
B. Clear items from the patient’s surrounding area
C. Loosen the patient’s restrictive clothing
D. Lower the patient to the floor
Answer: D. Lower the patient to the floor
57. A nurse is teaching a patient who is receiving total parenteral nutrition at home through a
central venous access device about transparent dressing changes. Which of the following
instructions should the nurse include in the teaching?
A. Change the dressing every 48 hr no
B. Replace the extension tubing with each dressing change no 72 hours
C. Use clean technique when changing the dressing no Surgical aseptic
D. Wear a mask during dressing change Surgical asepsis required
Answer: D. Wear a mask during dressing change Surgical asepsis required
58. A nurse is caring for a patient in the emergency department who experienced a full-thickness
burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?
During a major burn the initial phase will activate the Sympathetic nervous system.
A. Decreased respiratory rate-its is increased
B. Hypotension
C. Bradycardia- tachycardia is what you will find
D. Urinary diuresis -decreased urine output is what you will find
Answer: B. Hypotension
59. A nurse in an emergency department is assessing a patient who has cirrhosis of the liver.
Which of the following is a priority finding?
A. Spider angiomas
B. Palmar erythema
C. Mental confusion
D. Yellow Sclera
Answer: C. Mental confusion
60. A nurse is providing instructions about foot care for a patient who has a peripheral arterial
disease. The nurse should identify which of the following statements by the patient indicates an
understanding of the teaching?
A. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning” no
B. “I use my heating pad on a low setting to keep my feet warm” no
C. “I soak my feet in hot water before trimming my toenails”
D. I rest in my recliner with my feet elevated for about an hour every afternoon”
Answer: D. I rest in my recliner with my feet elevated for about an hour every afternoon”
61. A nurse is teaching a patient who has a new prescription for alendronate to treat osteoporosis.
Which of the following instructions should the nurse include in the teaching?
A. Swallow the medication with 120mL (4 oz) of water (Must be 8 oz of water)
B. Take the medication with a vitamin E supplement (Pretty sure you need vitamin D instead
since this drug is for helping with osteoporosis)
C. Sit upright for 30 min after taking the medication (No lying down)
D. Take the medication with lunch (Must be taken early morning before eating)
Answer: C. Sit upright for 30 min after taking the medication (No lying down)
62. A nurse is teaching a patient about using a metered dose rescue inhaler. Which of the
following statements should the nurse include in the teaching?
A. Depress the canister after you inhale
B. Exhale fully before bringing the inhaler to your lips
C. Do not shake your inhaler before use
D. Use peroxide to clean the mouth of your inhaler
Answer: B. Exhale fully before bringing the inhaler to your lips
63. A nurse is admitting a patient to the emergency department after a gunshot wound to the
abdomen. Which of the following actions should the nurse take to help prevent the onset of acute
kidney failure?
A. Initiate beta blocker therapy- it says use CCB to prevent movement of calicum into kidney
cells and maintain cell integrity.
B. Insert a urinary catheter
C. Prepare the patient for intravenous pyelogram
D. Administer IV fluids to the patient- to promote kidney perfusion if patient is in the dieretic
phase
Answer: D. Administer IV fluids to the patient- to promote kidney perfusion if patient is in the
dieretic phase
64. A nurse is completing an assessment of an older adult patient and notes redness areas over the
bony prominences, but the patient’s skin is intact. Which of the following interventions should
the nurse include in the plan of care?
A. Apply an occlusive dressing
B. Manage the redness areas three times daily
C. Support bony prominences with pillows
D. Turn and reposition the patient every 4 hr.
Answer: C. Support bony prominences with pillows
65. A nurse is caring for a patient who has completed 10 daily cycles of Total parenteral
Nutrition (TPN). Which of the following findings indicates that the patient is receiving adequate
TPN supplementation.
A. Improved Mobility (Doesn’t correlate to TPNs)
B. Weight gain of 9.1 kilograms to 20 pounds (TPNs are intended for patients who are
malnourished so gaining 2 pounds in 2 days is good.)
C. Potassium level of 2.5 mEq/l (Potassium should be in normal range since tpn is intended
formal nourished patients and contains electrolytes and vitamins that the patient needs.)
D. BUN level of 15 mg/dL
Answer: D. BUN level of 15 mg/dL
66. A nurse is providing teaching to a patient who is post-operative following a partial
glossectomy. Which of the following statements by the patient indicates an understanding of the
teaching?
A. I will consume can soup whenever sores appear in my mouth
B. I will drink orange juice to increase my vitamin C intake- NO ACIDIC stuff in the mouth
C. I will rinse my toothbrush with hydrogen peroxide and water after each use
D. I will inspect my mouth once each week for sores.
Answer: C. I will rinse my toothbrush with hydrogen peroxide and water after each use
67. A nurse is performing an ear irrigation for a patient. Which of the following actions should
the nurse take?
A. tilt the patient's head 45 degrees
B. Insert the tip of the syringe to .5 centimeters 1 inch into the ear canal
C. Point the tip of the syringe toward the top of the ear canal
D. Use cool fluid for irrigation
Answer: C. Point the tip of the syringe toward the top of the ear canal
68. A nurse is caring for a patient who is receiving continuous bladder irrigation following a
transurethral resection of the prostate (TURP). The patient reports sharp lower abdominal pain.
Which of the following actions should the nurse take first?
A. Check the patient's urine output
B. Reposition the patient in bed
C. Increase the patient's fluid intake
D. administer PRN pain medication
Answer: A. Check the patient's urine output
69. A nurse is providing teaching for a patient who has diabetes mellitus about the selfadministration of insulin. The patient has prescriptions for regular and NPH insulin. Which of the
following statements by the patient indicates an understanding of the teaching?
A. I will draw up regular insulin into the syringe first
B. I will insert the needle at a 15 degree angle - 45 degree
C. I will store prefilled syringes in the refrigerator with the needle pointing downward
D. I will shake the NPH vial vigorously before drawing up the insulin= you can only roll it to
mix it
Answer: A. I will draw up regular insulin into the syringe first
70. A nurse is caring for a patient who is receiving Total parenteral Nutrition (TPN). which of the
following nursing actions are appropriate? (Select all the apply)
A. Obtain the patient's weight daily
B. Increase the rate of infusion if administration is delayed
C. Monitor serum blood glucose during infusion
D. Use 0.9% sodium chloride if the solution is not available
E. Verify the solution with another RN prior to infusion
Answer: A. Obtain the patient's weight daily
C. Monitor serum blood glucose during infusion
E. Verify the solution with another RN prior to infusion
71. A nurse is caring for a patient in diabetic ketoacidosis dka. Which of the following is the
priority intervention by the nurse?
A. Check potassium levels
B. Administer 0.9% sodium chloride - always treat underlying cause which is done by giving
rapid isotonic fluid replacement so you can MAINTAIN PERFUSION TO VITAL ORGANS.
C. Begin bicarbonate continuous IV infusion
D. Initiate continuous IV insulin infusion
Answer: D. Initiate continuous IV insulin infusion
72. A nurse is reviewing the laboratory results of a female patient who asked about acupuncture
treatment for chemotherapy-induced nausea and vomiting. Which of the following laboratory
results indication to receiving acupuncture?
A. Absolute neutrophil count 500/mm3
B. C-reactive protein 0.7 mg/dl
C. platelets 160000/mm3
D. Hemoglobin 12 /dl
Answer: A. Absolute neutrophil count 500/mm3
73. A nurse is caring for a patient following a total knee arthroplasty. The patient reports a pain
level of 6 on a Pain Scale of 0 to 10. which of the following should the nurse take?
A. Gently massage the area around the patients incision
B. Place pillows under the patient's knee
C. Apply and ice path to the patient’s knee- prevent swelling
D. Perform range of motion exercises to the patient’s knee- DO NOT, we want to prevent flexion
contractures.
Answer: C. Apply and ice path to the patient’s knee- prevent swelling
74. A nurse is Assessing a patient who has heart failure and is receiving a loop diuretic. Which of
the following findings indicates hypokalemia?
A. Hypertension- low K if make low blood pressure, weak thready pulse, and orthostatic hypp.
B. Positive chvostek's sign - signs of low calcium
C. Muscle weakness
D. Oliguria
Answer: C. Muscle weakness
75. A nurse at a long-term care facility is assessing an older adult patient. Which of the following
findings should the nurse identify as an indication that the patient has recall memory
impairment?
A. Inability to state what he has for dinner last night
B. Inability to Name the members of his family
C. Inability to count backwards from 10
D. Inability to state his current age
Answer: A. Inability to state what he has for dinner last night
76. A nurse on an intensive care unit is planning care for a patient who has increased intracranial
pressure following a head injury. Which of the following IV medications should the nurse plan to
administer?
A. Chlorpromazine
B. Dobutamine
C. Mannitol.
D. Propranolol
Answer: C. Mannitol.
77. A nurse on a medical unit is planning care for a group of patients. Which of the following
patients should the nurse attend to First?
A. A patient who has thrombocytopenia and reports and nosebleed
B. A patient who has chronic obstruction pulmonary disease and oxygen saturation of 89%
C. A patient who has multiple sclerosis and Ataxia and vertigo
D. A patient who has left-sided paralysis and slurred speech from a prior stroke
Answer: A. A patient who has thrombocytopenia and reports and nosebleed
78. A home care nurse is planning to use non pharmacological pain relief measures for an older
patient who has severe chronic back pain. Which of the following guidelines should the nurse
use?
A. Use imagery with patients who have difficulty with focus and concentration
B. Pain relief from the use of heat and cold continues for several hours after removal of the
stimulus
C. Discontinue opioids before trying non pharmacological methods of pain relief
D. Distraction changes the patient's perception of pain but does not affect the cause
Answer: D. Distraction changes the patient's perception of pain but does not affect the cause
79. A nurse is caring for a patient who has pneumothorax and a chest tube with closed water seal
drainage system. Which of the following actions should the nurse take?
A. Strip or clear the chest tube every 8hours
B. Refill the water chamber if the fluid is low
C. Empty the system at least every 8 hr
D. Change the chest to site dressing every 24 hour
Answer: B. Refill the water chamber if the fluid is low
80. A nurse is in an emergency department is reviewing a patient's ECG reading. which of the
following findings should the nurse identify as an indication that the patient has first degree heart
block?
A. Prolonged PR intervals (Per Tiamson)
B. More p waves than QRS complexes
C. Non discernible p waves
D. No correlation between p and QRS waves
Answer: A. Prolonged PR intervals (Per Tiamson)
81. A nurse is preparing to administer a unit of packed rbc's to a patient who is anemic. Identify
the sequence of steps the nurse should follow.
Answer: A. Obtain venous access using a 19 gauge needle
B. Obtain the unit of packed rbc's from Blood Bank align
C. verify blood compatibility with another nurse
D. Initiate transfusion of the unit of packed rbc's
E. Remain with the patient for the first 15 to 30 minutes of the infusion
82. A nurse is teaching A patient who is to begin chemotherapy about peripherally inserted
Central catheter. Which of the following statements should the nurse include in the teaching?
A. We will replace the PICC every month
B. We can draw blood samples from the PICC for diagnostic test
C. We will change the dressing daily
D. We can measure your blood pressure in either arm
Answer: B. We can draw blood samples from the PICC for diagnostic test
Rationale: ATI Med-Surg p. 166 PICC lines can be used up to 12 months, change gauze
dressings every 48 hours and transparent dressings 3 to 7 days or whenever they are no longer
intact. Measure BP in opposite arm
83. A nurse is assessing a patient who has Pyelonephritis and reports flank pain. which of the
following actions should the nurse take?
A. Assist the patient to a sitting position
B. Percuss the side of tenderness first
C. Auscultate for a bruit over the coastal vertebral area
D. Thump the area of tenderness directly with a closed fist
Answer: A. Assist the patient to a sitting position
84. A nurse is assessing a patient who has acute kidney failure. Which of the following findings
should the nurse report to the provider?
A. Peripheral pulses 2 + bilaterally
B. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
C. Urine specific gravity 1.045
D. Creatinine 0.8 milliliter
Answer: B. Weight gain 1.1 kilogram to 2.4 pound in 24-hour
Rationale: weight gain can indicate fluid retention. normal urine specific gravity: 1.000-1.030,
normal creatinine: 0.5-1.2
85. A nurse is caring for an older adult patient who is 72 hour postoperative following a total hip
arthroplasty. the patient requires a PRN medication prior to ambulation. Which of the following
medications should the nurse anticipate administering?
A. Indomethacin
B. Meperidine
C. Naproxen
D. Oxycodone
Answer: C. Naproxen
86. A nurse is caring for a patient who has Haemophilus Influenzae type B. which of the
following types of isolation should the nurse implement?
A. Droplet
B. Contact
C. Airborne
D. Protective
Answer: A. Droplet
87. A nurse is providing discharge teaching to a patient who has pulmonary tuberculosis. Which
of the following findings should the nurse include as an indication the patient is no longer
infectious?
A. Mantoux skin test reveals an induration of less than 1 mm
B. Patient no longer coughing up blood-tinged sputum
C. Positive Quantiferon-TB Gold test
D. Negative sputum culture for acid-fast bacillus
Answer: D. Negative sputum culture for acid-fast bacillus
88. A nurse working in the emergency department is caring for a patient who has a burn injury.
After securing the patient's Airway which of the following interventions should the nurse take
first?
A. Cleanse the patient wound
B. Administer Analgesic medication
C. Increase the room temperature
D. Start an IV with a large bore needle
Answer: D. Start an IV with a large bore needle
89. A nurse is caring for a patient who has a central venous access device and notes the tubing
has become disconnected. The patient develops dyspnea and tachycardia. Which of the following
actions should the nurse take first?
A. Obtain ABG values
B. Perform an ECG
C. Turn the patient to his left side
D. Clamp the catheter
Answer: D. Clamp the catheter
90. A nurse is providing discharge teaching to a patient who has impaired immune system due to
chemotherapy. Which of the following information should the nurse include in the teaching?
A. Wash your perineal area 2 times each day with antimicrobial soap
B. Change the water in your drinking glass every 4 hours p.581 avoid fluids sitting at room temp
for longer than 1hr
C. Wash your toothbrush in the dishwasher once each month p.581 wash toothbrush daily in
dishwasher
D. Change your pet litter box daily p.581 avoid changing pet’s litter box
Answer: A. Wash your perineal area 2 times each day with antimicrobial soap
