Med Surg ATI Med Test Bank QUESTIONS AN CORRECT ANSWERS
VERIFIED 2023 UPDATE
MAIN VERSION PRIORITY ONE
1. A nursing planning care for a school-age child who is 4 hrs. postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
A. Offer small amounts of clear liquids 6 hrs. following surgery (assess for gag reflex first)
B. Give cromolyn nebulizer solution every 6 hrs. (for asthma)
C. Apply a warm compress to the operative site every 4 hrs.
D. Administer analgesics on a scheduled basis for the first 24 hrs.
Answer: D. Administer analgesics on a scheduled basis for the first 24 hrs.
Rationale:
Managing acute severe pain with short term (24 to 48 hrs.)around the clock administration of
opioids is preferable to following a PRN schedule.
Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated
on ATI.
2. A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has diabetes mellitus and a haemoglobin A1C of 6.8%
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has a hip fracture and a new onset of tachypnea
Answer: D. A client who has a hip fracture and a new onset of tachypnea
Rationale:
s/s of fat embolism (dyspnea, increased RR, decreased O2, headache, decreased LOC r/t low O2
levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures are
common causes, can occur after injury usually within 12-48 hrs.
3. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following
actions should the nurse take?
A. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
B. Wear gloves to apply the patch to the client’s skin
C. Apply the patch within 1 hrs. of removing it from the protective pouch (apply immediately)
D. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed
together)
Answer: B. Wear gloves to apply the patch to the client’s skin
Rationale:
Topical medications include lotions, creams, ointments, patches, and paste. Because topical
medications are absorbed by the skin, wear gloves when applying them to protect yourself
against accidental exposure
Shaving may cause skin irritation and change the absorption of the drug.
4. A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
A. A client who was just given a glass of orange juice for a low blood glucose level
B. A client who is schedule for a procedure in 1 hrs. (can wait)
C. A client who has 100 mL fluid remaining in his IV bag (can wait)
D. A client who received a pain medication 30 min ago for postoperative pain
Answer: A. A client who was just given a glass of orange juice for a low blood glucose level
Rationale:
Assess for improvement or worsening of hypoglycemia. Repeat the administration of
carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure
& coma if condition worsens.
5. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A. A history of gastroesophageal reflux disease
B. Receiving a high osmolarity formula
C. Sitting in a high-Fowler’s position during the feeding
D. A residual of 65 mL 1hr postprandial
Answer: A. A history of gastroesophageal reflux disease
Rationale:
Complications: Aspiration of gastric secretion, causes: Reflux of gastric fluids into the esophagus
can be aspirated into the trachea.
6. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse
should expect the client to have an INCREASED in which of the following laboratory values?
A. Serum glucose level- increased
B. Serum calcium level-decreased
C. Lymphocyte count- decreased immune system.
D. Serum potassium level- decreased
Answer: A. Serum glucose level- increased
Rationale:
Cushing disease" everything is UP except Potassium & Calcium: DECREASED.
7. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take?
A. Position the client supine
B. Prepare an IV bolus of dextrose 5% in water
C. Administer methylergonovine IM
D. Administer calcium gluconate IV
Answer: D. Administer calcium gluconate IV
Rationale:
Calcium gluconate is given for magnesium sulphate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulphate by IV.
8. A charge nurse is teaching new staff members about factors that increase a client’s risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
A. Experiencing delusions
B. Male gender
C. Previous violent behavior
D. A history of being in prison
Answer: C. Previous violent behavior
Rationale:
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent
angry reactions with cognitive disorders).
Individual Assessment for Violence
9. A nurse is preparing to perform a sterile dressing change. Which of the following actions
should the nurse take when setting up the sterile field?
A. Place the cap from the solution sterile side up on clean surface
B. Open the outermost flap of the sterile kit toward the body" flap AWAY from the body's first
C. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field " 2.5 cm (1inch) border around any sterile drape or wrap that is considered contaminated.
D. Set up the sterile field 5 cm (2 in) below waist level" it says BELOW waist level; should be
ABOVE waist level
Answer: A. Place the cap from the solution sterile side up on clean surface
Rationale:
Remove sterile seal and cap from bottle in upward motion.
10. A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Eat a light snack before bedtime
B. Stay in bed at least 1 hrs. if unable to fall asleep
C. Take a 1 hrs. nap during the day
D. Perform exercises prior to bedtime
Answer: A. Eat a light snack before bedtime
11. A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first?
A. Educate the client about current medical diagnosis
B. Refer the client to a meal delivery program
C. Identify environmental hazards in the home
D. Arrange for client transportation to follow-up appointments
Answer: C. Identify environmental hazards in the home
Rationale:
Assess first.
12. A nurse is assessing the remote memory of an older adult client who has mild dementia.
Which of the following questions should the nurse ask the client?
A. “Can you tell me who visited you today?”
B. “What high school did you graduate from?”
C. “Can you list your current medications?”
D. “What did you have for breakfast yesterday?”
Answer: B. “What high school did you graduate from?”
Rationale:
ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask
the client to state a fact from their past that is verifiable. Memory of events that occurred in the
distant past.
13. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the
following goals should the nurse include in the teaching?
A. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON-COMPLIANT
B. Blood glucose level greater than 200 mg/dL at bedtime
C. Blood glucose level less than 60 mg/dL before breakfast- 4,800 is normal
C. Creatinine 0.9 mg/dL, < 1.0 is normal
D. Potassium 5.2 mEq /L 3.5 - 5.0 = imbalance = CARDIAC DYSRHYTHMIAS
Answer: D. Potassium 5.2 mEq /L 3.5 - 5.0 = imbalance = CARDIAC DYSRHYTHMIAS
Rationale:
Avoid NA, K, Mg, Phosphorus. Imbalances before surgery
168. A nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching?
A. Engage the client in activities that increase sensory stimulation.
B. Discourage physical activity during the day
C. Establish a toileting schedule for the client
D. Use clothing with buttons and zippers
Answer: C. Establish a toileting schedule for the client
169. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about
overtime requirements. Which of the following strategies should the charge nurse use to promote
effective negotiation?
A. Identify Solutions prior to negotiation
B. personalize the conflict
C. Attempt to understand both sides of the issue
D. Focus on how the conflict occurred
Answer: C. Attempt to understand both sides of the issue
Rationale:
Assess the situation first prior to trying to solve it.
170. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at
the peripheral IV site. Which of the following actions should the nurse plan to take?
A. Insert a new IV catheter distal to the discontinued IV site
B. apply pressure dressing at the IV site
C. Please a warm moist compress on the site
D. Express drainage from the IV site and send it to be cultured
Answer: C. Please a warm moist compress on the site
Rationale:
Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is
commonly treated by discontinuing the IV line and applying a moist, warm compress over the
area.
171. A nurse is preparing to administer three medications to a client who is receiving continuous
enteral tube feeding through an NG tube. Which of the following actions is appropriate for the
nurse to take?
A. ADD medication directly to enteral feeding - not without crushing them first
B. Dissolve the medications together- some medications can mix others can’t
C. Use a syringe to allow the medications to Flow by gravity
D. Flush the NG tube with 5 ml water- 10ml
Answer: C. Use a syringe to allow the medications to Flow by gravity
172. The nurse is caring for a client who has histrionic personality disorder. Which of the
following findings should the nurse expect?
A. Repeated acts of unlawful Behavior
B. Suspicious demeanor
C. Seductive Behavior
D. Lack of remorse
Answer: C. Seductive Behavior
Rationale:
They want attention
173. A nurse in a prenatal Clinic is teaching a client about non-pharmacological pain
management during labor. Which of the following statements by the client indicates an
understanding of the teaching?
A. My nurse can teach me biofeedback at the beginning of labor- biofeedback would be taught
earlier to control other pain, not pain of labor
B. A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would mess
with the readings of the pt. and baby
C. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no.
D. I can use my ultrasound picture as a focal point during contractions- Distraction
Answer: D. I can use my ultrasound picture as a focal point during contractions- Distraction
174. A nurse is assessing a client Telemetry strip. Which of the following findings should the
nurse report to the provider?
A. Heart rate 98 per minute - WNL
B. ST segment elevations_ Remember this could possibly lead to infarctions
C. 2 PVCs per minute
D. Widened P wave
Answer: B. ST segment elevations_ Remember this could possibly lead to infarctions
175. A nurse is observing a newly licensed nurse who is administering Total Parenteral Nutrition
TPN to a client. Which of the following actions by the newly licensed nurse indicates a need for
the nurse to intervene?
A. Plans for a check of the clients fingerstick glucose every 6 hours
B. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok
C. Uses the TPN IV tubing to administer the clients next dose of antibiotics- start another
IV/lock for antibiotic, can’t use with TPN
D. Increases the TPN infusion rate each hour until the prescribed rate is achieved
Answer: C. Uses the TPN IV tubing to administer the clients next dose of antibiotics- start
another IV/lock for antibiotic, can’t use with TPN
176. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading
a group on a mental health unit. which of the following group facilitation techniques should the
nurse include in the teaching?
A. Yield in situations of conflict to maintain group Harmony - If conflict arises it is your
responsibility to contain it
B. Share personal opinions to help influence the group's values -your focus is having group share
their personal thoughts and feelings to facilitate discussion
C. Use modelling to help the clients improve their interpersonal skills
D. Measure the accomplishments of the group against a previous group - no comparison
Answer: C. Use modelling to help the clients improve their interpersonal skills
177. A nurse is assessing a client's respirations which of the following actions should the nurse
take?
A. Assess respirations before counting radial pulsations -either or is fine
B. Multiply the number of respirations in 15 seconds by 4 - short way to do it, not necessarily the
right way
C. Inform the client that has breaths will be counted- may raise or lower breath rate due to fear
D. Count respirations for 1 minute if the rhythm is irregular
Answer: D. Count respirations for 1 minute if the rhythm is irregular
178. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of
the client’s biopsy report while on the elevator. Which of the following actions should the nurse
take?
A. Report the information to the charge nurse
B. review confidentiality policies with laboratory employees- would be the job of the Facility
manager or someone who audits or teaches HIPAA stuff
C. contact the laboratory manager regarding the situation - you are not high enough up the chain
to do that
D. Notify the facilities legal department - no need to go that far
Answer: A. Report the information to the charge nurse
179. A nurse is assessing a client who requests an oral contraceptive. Which of the following
findings in the client’s medical history should the nurse identify as a contraindication for the use
of a combination oral contraceptive?
A. Concurrent use of levothyroxine
B. Allergy to penicillin
C. Recurrent urinary tract infections
D. Migraines with aura
Answer: D. Migraines with aura
Rationale:
Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or
heart disease.
180. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the
following clients should the nurse see first?
A. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 (Normal 810)
B. A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
C. A client who is at 28 weeks of gestation and reports leukorrhea
D. A client who has preeclampsia and reports a persistent headache
Answer: D. A client who has preeclampsia and reports a persistent headache
181. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the
following actions should the nurse include in the plan of care?
A. Instruct the client to empty her bladder prior to the procedure.
B. Position the client over an overbed table prior to the procedure.
C. Administer 1 L dextrose 5% in water IV bolus prior to the procedure.
D. Initiate NPO status 4 hrs. prior to the procedure.
Answer: A. Instruct the client to empty her bladder prior to the procedure.
Rationale:
Preprocedural nursing actions: Have the client void, or insert an indwelling urinary catheter.
182. A nurse is caring for a client who is in active labor and notes the FHR baselines has been
100/min for the past 15 min. The nurse should the identify which of the following conditions as a
possible cause of fetal bradycardia?
A. Maternal hypoglycemia
B. Uteroplacental insufficiency
C. Prolonged umbilical cord compression
D. Maternal hypotension
Answer: B. Uteroplacental insufficiency
Rationale:
FHR <110/min; complications: Uteroplacental insufficiency, umbilical cord prolapse, maternal
hypotension, prolonged umbilical cord compression, fetal congenital heart block, anesthetic
medications, viral infection, maternal hypoglycemia, fetal heart failure, maternal hypothermia
183. A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so
quickly.” Which of the following responses by the nurse is therapeutic?
A. “You should make sure your partner takes the prescribed medication.”
B. “Why do you think your partner’s symptoms are progressing so quickly?”
C. “You did the right thing by bringing your partner in for treatment.”
D. “Can you talk about what was happening with your partner at home? ”
Answer: D. “Can you talk about what was happening with your partner at home? ”
184. A nurse is assessing a client who is prescribed valproic acid. Which of the following
laboratory tests should the nurse monitor?
A. Arterial blood gas
B. Serum potassium
C. Liver function test
D. Serum creatinine cc
Answer: C. Liver function test
185. A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a
client. Which of the following statements should the nurse include in the teaching?
A. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
B. “The PCA will deliver a double dose of medication when you push the button twice.”
C. “You should push the button before physical activity to allow maximum pain control.”
D. “You can adjust the amount of pain medication you receive by pushing on the keypad.”
Answer: C. “You should push the button before physical activity to allow maximum pain
control.”
186. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an
appropriate action for the nurse to take?
A. Discard the first 10 mL of urine.
B. Apply EMLA cream prior to the procedure.
C. Obtain a 12 French catheter.
D. Don sterile gloves prior to the procedure.
Answer: D. Don sterile gloves prior to the procedure.
187. A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which
of the following levels should the nurse report to the provider?
A. Potassium 3.2 mEq/L 3.5 - 5.0 is normal
B. BUN 16 mg/dL (Normal 10-20)
C. PT 12.2 seconds (Normal 11-14)
D. Fasting blood glucose 103 mg/Dl
Answer: A. Potassium 3.2 mEq/L 3.5 - 5.0 is normal
188. A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.”
Which of the following responses is the priority for the nurse to state?
A. “How long have you been hearing the voices?”
B. “What are the voices telling you?”
C. “Have you taken your medication today?”
D. “I realize the voices are real to you, but I don’t hear anything.”
Answer: B. “What are the voices telling you?”
