ATI Adult Medical-Surgical Nursing Nclex Most Asked Questions
ATI Adult Medical-Surgical Nursing
Nclex Questions
1. A nurse in an emergency department is assessing a client who was in a MVC. Findings
include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg,
heart rate 124/min, respirations 38/min, temperature 38.6℃ (101.4℉), and SaO2 92% on room
air. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high-flow mask.
D. Initiate IV access.
Rationale: C- According to the airway, breathing, and circulation to client care, the nurse should
place the priority on administering oxygen via high-flow mask to provide the client oxygen to
restore optimal breathing.
2. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a
client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching?
A. “This medication is given to treat infection.”
B. “This medication is given to facilitate ventilation.”
C. “This medication is given to decrease inflammation.”
D. “This medication is given to reduce anxiety.”
Rationale: B- Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and
decrease oxygen consumption.
3. A nurse is reviewing the health records of five clients. Which of the following clients are at
risk for developing acute respiratory distress syndrome? (Select all that apply.)
A. A client who experienced a near-drowning incident
B. A client following a coronary artery bypass graft surgery.
C. A client who has a hemoglobin of 15.1 mg/Dl
D. A client who has dysphagia
E. A client who experienced a drug overdose
Rationale: A, B, D, E- A client who experienced a near-drowning incident is at risk for
developing ARDS due to trauma to the lungs and cerebral edema. A client following coronary
artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. A client
who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for
aspiration. A client who experienced a drug overdose is at risk for developing ARDS due to
damage to the central nervous system.
4. A nurse is planning care for a client who has severe acute respiratory distress system (SARS).
Which of the following actions should be included in the plan of care for the client? (Select all
that apply.)
A. Administer antibiotics.
B. Provide supplemental oxygen.
C. Administer antiviral medications.
D. Administer of bronchodilators.
E. Maintain ventilatory support.
Rationale: B, D, E- Providing supplemental oxygen should be included in the plan of care for
SARS. Oxygen is administered given to treat severe hypoxemia. Administering of
bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to
vasodilate the client’s airway. Maintaining ventilatory support should be included in the plan of
care for SARS. Intubation can be required to maintain a patent airway.
5. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress
syndrome. Which of the following medications should the nurse anticipate administering with
this medication? (Select all that apply.)
A. Fentanyl
B. Furosemide
C. Midazolam
D. Dexamethasone
Rationale: A, C- Fentanyl is a pain medication used to treat clients who have ARDS when a
neuromuscular blocking agent such as vecuronium is administered. Midazolam is a sedative
medication used to treat clients with ARDS when a neuromuscular blocking agent such as
vecuronium is administered.
Chapter 27 – Cardiovascular Diagnostic and Therapeutic Procedures
1. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed
for hemodynamic monitoring. Which of the following statements by the newly licensed nurse
indicates effectiveness of the teaching?
A. “Air should be instilled into the monitoring system prior to the procedure.”
B. “The client should be positioned on the left side during the procedure.”
C. “The transducer should be level with the second intercostal space after the line is placed.”
D. “A chest x-ray is needed to verify placement after the procedure?”
Rationale: D- The nurse should ensure that a chest x-ray is obtained to confirm proper placement
of the lines following placement.
2. A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a
CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following finding should the nurse
expect?
A. Poor skin turgor
B. Bilateral crackles in the lungs
C. Jugular vein distension
D. Dry mucous membranes
E. Hepatomegaly
Rationale: B, C, E- The nurse should expect the client to have bilateral crackles in the lungs for
an increased CVP and PAWP. The nurse should expect the client to have jugular vein distention
for an increased CVP and PAWP. The nurse should expect the client to have hepatomegaly for
an increased CVP and PAWP.
3. A nurse is teaching a client who is scheduled for an angiography. Which of the following
statements should the nurse include in the teaching? (Select all that apply.)
A. “You should have nothing to eat or drink for 4 hours prior to the procedure.”
B. “You will be given general anesthesia during the procedure.”
C. “You should not have this procedure done if you are allergic to eggs.”
D. “You will need to keep your affected leg straight following the procedure.”
Rationale: D- The nurse should instruct the client of the need to remain on bed rest in the supine
position with the affected leg straight for a prescribed amount of time. This positioning
decreases the client’s risk for bleeding and hematoma formation at the catheter insertion site.
4. A nurse at a provider’s office is reviewing the laboratory test results for a group of clients.
The nurse should identify that which of the following results indicates the client is at risk for
heart disease? (Select all that apply.)
A. Cholesterol (total) 245 mg/Dl
B. HDL 90 mg/dL
C. LDL 140 mg/Dl
D. Triglycerides 125 mg/Dl
E. Troponin I 0.02 ng/mL
Rationale: A, C- A client who has a total cholesterol level greater than 200 mg/Dl is at increased
risk for heart disease. A client who has an LDL greater than 130 mg/Dl is at increased risk for
heart disease.
5. A nurse is planning care for a client who has a PICC line in the right arm. Which of the
following interventions should the nurse include in the plan of care? (Select all that apply.)
A. Use a 10 mL syringe to flush the PICC line.
B. Apply gentle force if resistance is met during injection.
C. Cleanse ports with alcohol for 15 seconds prior to use.
D. Maintain a transport dressing over the insertion sit.
E. Flush with 10 mL heparin before and after medication administration.
Rationale: A, C, D- The nurse should use a 10 mL syringe to flush the PICC line to avoid excess
pressure that could cause catheter fracture/rupture. The nurse should cleanse insertion ports with
alcohol for 15 seconds and allow it to air dry prior to use. This action decreases the risk for
bacterial contamination. The nurse should maintain a transparent dressing over the insertion site
to decrease the risk for infection and allow for visualization. The nurse should plan to change
the dressing at least every 7 days and when wet, loose, or soiled.
Chapter 28 – Electrocardiography and Dysrhythmia Monitoring
1. A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of
the following clients as being at risk for the development of a dysrhythmia? (Select all that
apply.)
A. A client who has metabolic alkalosis
B. A client who has a serum potassium level of 4.3 mEq/L
C. A client who has an SaO2 of 96%
D. A client who had COPD
E. A client who underwent stent placement in a coronary artery
Rationale: A, D, E- A client who has an acid-base imbalance such as metabolic alkalosis is at risk
for a dysrhythmia. A client who has lung disease, such as COPD, is at risk for a dysrhythmia. A
client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia.
2. A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and
is reviewing the health record. Which of the following data requires that the nurse notify the
provider to cancel the procedure? (Review the data below for additional client information)
MAR:
Ferrous Sulfate 200 mg PO 0800 and 2000
Diazepam 2 mg PO 0800 and 2000
Isosorbide 2.5 mg PO 4 times a day AC and HS
VITAL SIGNS:
0800 – T 99.5F
Blood pressure 142/86 mm Hg
Heart rate 88/min and irregular
Respirations 20/min
HISTORY & PHYSICAL:
Bariatric surgery 10 years ago
Dyspnea with exertion for 3 years
Atrial fibrillation began 3 years ago
Client reports taking the following medications for the past 6 weeks: Iron supplement,
multivitamin, antilipemic, and nitroglycerin
A. Respiratory history
B. Vital signs
C. Medication history
D. Medications to be administered
Rationale: C- A client who is to undergo cardioversion needs to be on anticoagulant therapy for
4-6 weeks prior to the procedure.
3. A nurse is caring for a client who experienced defibrillation. Which of the following should
be included in the documentation of this procedure? (Select all that apply.)
A. Follow-up ECG
B. Energy settings used
C. IV fluid intake
D. Urinary output
E. Skin condition under electrodes
Rationale: A, B, E- The client’s ECG rhythm is documented following the procedure. Energy
settings used during the procedure are documented. The condition of the client’s skin where the
electrodes were placed is documented.
4. A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the
client’s heart rate is 46/min and notifies the provider. The nurse should anticipate that which of
the following management strategies will be used for this client?
A. Defibrillation
B. Pacemaker insertion
C. Synchronized cardioversion
D. Administration of IV lidocaine
Rationale: B- A client who has bradycardia is a candidate for a pacemaker to increase the heart
rate.
5. A student nurse is observing a cardioversion procedure and hears the team leader call out,
“Stand clear.” The student should recognize the purpose of this action is to alert personnel that
A. The cardioverter is being charged to the appropriate setting.
B. They should initiate CPR due to pulseless electrical activity.
C. They cannot be in contact with equipment connected to the client.
D. A time-out is being called to verify correct protocols.
Rationale: C- A safety concern for personnel performing cardioversion is to “stand clear” of the
client and equipment connected to the client when a shock is delivered to prevent them from also
receiving a shock.
Chapter 29 – Pacemakers
1. A nurse is admitting a client who has complete heart block as demonstrated by ECG. The
client’s heart rate is 34/min and blood pressure is 83/48 mm Hg. The client is lethargic and
unable to complete sentences. Which of the following actions should the nurse perform first?
A. Transport the client to the cardiovascular laboratory.
B. Prepare the client for insertion of a permanent pacemaker.
C. Obtain a signed informed consent form for a pacemaker.
D. Apply transcutaneous pacemaker pads.
Rationale: D- The greatest risk to this client is injury or death from inadequate tissue perfusion;
therefore, the first action the nurse should take is to apply transcutaneous pacemaker pads and
begin external pacing of the heart until a permanent pacemaker can be placed.
2. A nurse is caring for a client following the insertion of a temporary venous pacemaker via the
femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings
should the nurse report to the provider? (Select all that apply.)
A. Cool and clammy foot with capillary refill of 5 seconds
B. Observed pacing spike followed by a QRS complex
C. Persistent hiccups
D. Heart rate 84/min
E. Blood pressure 104/62 mm Hg
Rationale: A, C- A cool, clammy foot can be an indication of a femoral hematoma secondary to
insertion of the lead wires and should be reported. Persistent hiccups can indicate lead wire
perforation and stimulation of the diaphragm and should be reported.
3. A nurse is completing discharge teaching with a client who has a permanent pacemaker.
Which of the following statements by the client indicates understanding of the teaching?
A. “I will notify the airport screeners about my pacemaker.”
B. “I will expect to have occasional hiccups.”
C. “I will have to disconnect my garage door opener.”
D. “I will take my pulse every 2 days.”
Rationale: A- The client should notify airport screening personnel about a pacemaker.
4. A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group
of newly hired nurses. Which of the following statements by a newly hired nurse indicates
understanding of the review?
A. “This means the pacemaker fires in an asynchronous pattern.”
B. “This means the pacemaker fires only when the heart rate is below a certain rate.”
C. “The pacemaker can automatically adjust to a client’s increased activity level.”
D. “The pacemaker activity is triggered by heart muscle activity.”
Rationale: A- Fixed rate mode is asynchronous, meaning the pacemaker fires without regard for
electrical activity in the heart.
5. A nurse is admitting a client to the coronary care unit following placement of a temporary
pacemaker. Which of the following nursing actions should the nurse use to promote client
safety? (Select all that apply.)
A. Wear gloves when handling pacemaker leads.
B. Ensure electronic equipment has three-pronged grounding plugs.
C. Minimize the client’s shoulder movements.
D. Hold the lead wires taut when turning the client.
E. Keep extra pacemaker batteries at least 300 feet away from the client.
Rationale: A, C- The nurse should wear gloves when handling pacemaker leads. The client
should wear a sling to minimize shoulder movement and promote secure anchoring of the lead
wires.
Ch. 30 – Invasive Cardiovascular Procedures
1. A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass
grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then
refuses to cough because he is tired and it hurts too much. Which of the following actions should
the nurse take?
A. Allow the client to rest, and return in 1 hr.
B. Administer IV bolus analgesic, and return in 15 min.
C. Document the 200 mL as an appropriate inspired volume.