ATI MEDSURG FINAL
EXAM NEWEST 2024
ACTUAL EXAM
COMPLETE
400+QUESTIONS AND
ANSWERS WITH
RATIONALES |ALREADY
GRADED A+
1.
2. Question: A nurse is caring for a patient with chronic obstructive pulmonary disease
(COPD). Which assessment finding would indicate that the patient is experiencing
respiratory distress?
○ Answer: Increased respiratory rate, use of accessory muscles, and cyanosis.
○ Rationale: In COPD patients, respiratory distress can manifest as an increased
respiratory rate due to hypoxia, the use of accessory muscles indicating labored
breathing, and cyanosis as a sign of inadequate oxygenation.
3. Question: A patient is receiving IV potassium chloride for hypokalemia. What should the
nurse monitor for to prevent complications?
○ Answer: Cardiac rhythm changes.
○ Rationale: Potassium is crucial for cardiac function, and IV administration can
cause hyperkalemia, leading to dangerous cardiac arrhythmias. The nurse
should continuously monitor the patient’s ECG.
4. Question: A patient presents with a sudden onset of severe chest pain and is
diaphoretic. What is the priority nursing intervention?
○ Answer: Administer oxygen and obtain vital signs.
○ Rationale: The sudden onset of chest pain, especially if associated with
diaphoresis, could indicate a myocardial infarction. Administering oxygen can
, help improve oxygenation to the heart, and monitoring vital signs is crucial for
detecting any changes in the patient’s condition.
5. Question: A nurse is teaching a patient with diabetes about foot care. Which statement
indicates a need for further teaching?
○ Answer: "I can soak my feet in hot water to relax them."
○ Rationale: Soaking feet, especially in hot water, can lead to skin breakdown or
burns in diabetic patients due to reduced sensation. Proper foot care includes
inspecting feet daily, keeping them clean and dry, and wearing well-fitting shoes.
6. Question: A patient with heart failure is prescribed a low-sodium diet. Which food choice
by the patient indicates a need for further teaching?
○ Answer: Canned soup.
○ Rationale: Canned soups often contain high amounts of sodium, which can
exacerbate heart failure symptoms by causing fluid retention. Patients should be
taught to read labels and choose low-sodium options.
6. Question: A patient who has just undergone a total hip replacement is in the recovery
room. Which of the following assessments is the priority for the nurse?
○ Answer: Assessing the patient's respiratory status.
○ Rationale: After surgery, it is crucial to monitor the patient’s respiratory status
due to the effects of anesthesia and potential for respiratory complications.
7. Question: A nurse is caring for a patient who is receiving a blood transfusion. Which
assessment finding should prompt the nurse to stop the transfusion?
○ Answer: Fever and chills.
○ Rationale: The presence of fever and chills may indicate a transfusion reaction,
and the nurse should stop the transfusion immediately and notify the healthcare
provider.
8. Question: A patient with cirrhosis is at risk for developing hepatic encephalopathy.
Which assessment finding would indicate the development of this complication?
○ Answer: Changes in level of consciousness and confusion.
○ Rationale: Hepatic encephalopathy occurs due to the accumulation of toxins in
the bloodstream from liver failure, leading to neurological changes such as
confusion and altered mental status.
9. Question: A nurse is teaching a patient about the use of an albuterol inhaler. What
statement by the patient indicates a correct understanding of the teaching?
○ Answer: "I should use this inhaler before exercising."
○ Rationale: Albuterol is a bronchodilator that can be used as a rescue inhaler to
relieve bronchospasm, and it is often used before physical activity to prevent
exercise-induced asthma symptoms.
10. Question: A patient diagnosed with a stroke has difficulty swallowing. Which of the
following interventions should the nurse implement first?
○ Answer: Keep the patient NPO (nothing by mouth).
○ Rationale: If a patient has difficulty swallowing, it is essential to keep them NPO
to prevent aspiration. A swallow evaluation should be conducted before allowing
oral intake.
11. Question: A patient with type 1 diabetes is admitted with diabetic ketoacidosis (DKA).
Which laboratory finding would the nurse expect to see?
○ Answer: Elevated blood glucose and low arterial blood pH.
○ Rationale: DKA is characterized by high blood glucose levels due to insufficient
insulin, along with metabolic acidosis indicated by a low arterial blood pH.
12. Question: The nurse is caring for a patient receiving a diuretic. Which lab result is most
critical to monitor?
○ Answer: Potassium level.
, ○ Rationale: Diuretics, especially loop and thiazide diuretics, can lead to
hypokalemia (low potassium levels), which can cause serious cardiac
complications.
13. Question: A nurse is caring for a patient who is experiencing an anaphylactic reaction.
What is the priority intervention?
○ Answer: Administer epinephrine.
○ Rationale: Epinephrine is the first-line treatment for anaphylaxis as it rapidly
reverses airway constriction and increases blood pressure.
14. Question: A patient with chronic kidney disease is on a low-protein diet. Which food
choice by the patient indicates a need for further education?
○ Answer: Grilled chicken.
○ Rationale: While protein is necessary, patients with chronic kidney disease often
need to limit protein intake to reduce the workload on their kidneys, so grilled
chicken may be inappropriate depending on their dietary restrictions.
15. Question: A nurse is caring for a patient with a newly inserted central venous catheter
(CVC). Which action is essential for preventing infection?
○ Answer: Performing hand hygiene before and after catheter care.
○ Rationale: Proper hand hygiene is critical in preventing infection associated with
the use of CVCs, as it significantly reduces the risk of introducing pathogens into
the bloodstream.
16. Question: A patient is experiencing chest pain and shortness of breath. Which
intervention should the nurse implement first?
○ Answer: Administer oxygen.
○ Rationale: Administering oxygen helps improve tissue oxygenation and is critical
in managing potential cardiac events.
17. Question: A nurse is assessing a patient with heart failure. Which symptom is most
indicative of fluid overload?
○ Answer: Peripheral edema.
○ Rationale: Peripheral edema is a common sign of fluid overload in heart failure,
indicating that the body is retaining excess fluid.
18. Question: A patient with a history of asthma is experiencing an acute asthma attack.
What is the priority nursing action?
○ Answer: Administer a short-acting beta-agonist (SABA).
○ Rationale: SABAs, such as albuterol, are used for immediate relief of asthma
symptoms by bronchodilation during an acute attack.
19. Question: The nurse is teaching a patient about the side effects of a new medication.
Which statement by the patient indicates a need for further teaching?
○ Answer: "I can stop taking the medication when I feel better."
○ Rationale: Patients should understand the importance of adhering to their
medication regimen and not discontinuing it without consulting their healthcare
provider, even if symptoms improve.
20. Question: A patient is being treated for hypertension. Which lifestyle change should the
nurse emphasize to help manage the patient's condition?
○ Answer: Reducing sodium intake.
○ Rationale: Reducing sodium intake can significantly help lower blood pressure
and is an essential component of lifestyle modifications for hypertension
management.
21. Question: A nurse is caring for a patient with pneumonia. Which finding would indicate a
positive response to treatment?
○ Answer: Improved oxygen saturation levels.
, ○ Rationale: Improved oxygen saturation indicates effective treatment of
pneumonia, as it reflects better gas exchange in the lungs.
22. Question: A patient is scheduled for a colonoscopy. What should the nurse teach the
patient about pre-procedure preparation?
○ Answer: You will need to follow a clear liquid diet the day before the procedure.
○ Rationale: A clear liquid diet is essential to ensure the colon is adequately
prepared for visualization during the colonoscopy.
23. Question: A patient is receiving warfarin therapy. Which laboratory test should the nurse
monitor regularly?
○ Answer: INR (International Normalized Ratio).
○ Rationale: The INR is a standardized measure used to assess the
anticoagulation effect of warfarin and ensure the patient is within the therapeutic
range.
24. Question: A nurse is assessing a patient with a suspected myocardial infarction (MI).
Which symptom would be most indicative of an MI?
○ Answer: Crushing chest pain that radiates to the left arm.
○ Rationale: Crushing chest pain, especially if it radiates to the left arm, is a
classic symptom of myocardial infarction and requires immediate medical
attention.
25. Question: A patient who is receiving chemotherapy is at risk for infection. Which
intervention should the nurse prioritize to reduce this risk?
○ Answer: Implement strict hand hygiene protocols.
○ Rationale: Hand hygiene is the most effective way to prevent the transmission of
infections, especially in immunocompromised patients.
26. Question: A nurse is teaching a patient with hypertension about dietary choices. Which
food should the patient avoid?
○ Answer: Processed foods.
○ Rationale: Processed foods often contain high levels of sodium, which can
exacerbate hypertension.
27. Question: A patient is receiving digitalis (digoxin). What is the most important parameter
for the nurse to monitor?
○ Answer: Heart rate.
○ Rationale: Digitalis can cause bradycardia; therefore, monitoring the heart rate is
essential to ensure it remains within a safe range.
28. Question: The nurse is caring for a patient with a history of peptic ulcer disease. Which
medication should the nurse question if prescribed?
○ Answer: Aspirin.
○ Rationale: Aspirin can irritate the gastric mucosa and increase the risk of
bleeding in patients with peptic ulcers.
29. Question: A patient with diabetes is experiencing hypoglycemia. Which symptom might
the nurse expect to find?
○ Answer: Sweating and trembling.
○ Rationale: Symptoms of hypoglycemia include autonomic responses like
sweating and trembling, which occur as the body reacts to low blood sugar
levels.
30. Question: A patient with chronic liver disease has an elevated ammonia level. What
symptom should the nurse monitor for that indicates hepatic encephalopathy?
○ Answer: Confusion or altered mental status.
○ Rationale: Elevated ammonia levels can lead to hepatic encephalopathy, which
manifests as confusion, lethargy, or altered consciousness.
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