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NURS 101 NR101 ATI Med-Surg proctored Exam
{Graded A+} Questions And Correct Answers (Verified
Answers) Plus Rationales 2025 Northeastern University
- A client with chronic kidney disease is scheduled for hemodialysis. Which lab value should the nurse monitor most closely before dialysis? a) Hemoglobin b) Potassium c) Calcium d) Sodium Rationale: Potassium levels can rise dangerously high in clients with kidney failure and must be monitored before dialysis to prevent cardiac arrhythmias.
- Which nursing intervention is most appropriate to prevent deep vein thrombosis (DVT) in a postoperative client? a) Encourage frequent coughing b) Restrict fluid intake c) Encourage early ambulation d) Apply cold compresses Rationale: Early ambulation helps promote circulation and reduces the risk of DVT in postoperative clients.
- A client is prescribed warfarin for atrial fibrillation. Which laboratory test will the nurse monitor to assess the medication’s effectiveness? a) Partial thromboplastin time (PTT) b) International Normalized Ratio (INR) c) Platelet count d) Hematocrit Rationale: The INR is used to monitor warfarin therapy to ensure therapeutic anticoagulation and prevent bleeding or clotting complications.
- Which symptom indicates a client with heart failure is experiencing fluid overload? a) Dry mucous membranes b) Weight loss c) Peripheral edema d) Decreased blood pressure Rationale: Peripheral edema is a classic sign of fluid overload in heart failure due to poor circulation and fluid retention.
- A nurse is caring for a client with pneumonia. Which finding indicates improvement in respiratory status? a) Increased use of accessory muscles b) Restlessness and agitation
- The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery method is most appropriate to maintain oxygen saturation between 88-92%? a) Non-rebreather mask at 15 L/min b) Nasal cannula at 6 L/min c) Venturi mask at 24-28% d) Simple face mask at 10 L/min Rationale: Venturi masks provide precise oxygen concentrations, ideal for COPD clients to prevent hyperoxia and CO2 retention.
- A client with peptic ulcer disease reports sharp epigastric pain two hours after eating. What is the likely cause of this pain? a) Gastric ulcer b) Duodenal ulcer c) Pancreatitis d) Gallbladder inflammation Rationale: Gastric ulcer pain typically worsens shortly after eating due to acid contacting the ulcerated stomach lining. 10.Which laboratory value would the nurse expect to be elevated in a client with an acute infection? a) Hemoglobin b) White blood cell count
c) Platelet count d) Serum potassium Rationale: White blood cell count typically increases during acute infection as part of the immune response. 11.A client is prescribed metformin for type 2 diabetes mellitus. Which instruction is important to include in teaching? a) Avoid foods high in potassium b) Report any signs of lactic acidosis, such as muscle pain or weakness c) Expect immediate insulin dependence d) Take with meals to avoid hypoglycemia Rationale: Metformin can cause lactic acidosis, so clients must report symptoms like muscle pain or weakness immediately. 12.Which clinical manifestation is most consistent with hypocalcemia? a) Muscle weakness b) Bradycardia c) Positive Chvostek’s sign d) Dry skin Rationale: Positive Chvostek’s sign (facial twitching) is a classic sign of hypocalcemia due to increased neuromuscular excitability.
Rationale: Weight gain over a short period suggests fluid retention; the nurse should assess for edema, lung sounds, and other signs before notifying the provider. 16.Which assessment finding indicates ineffective airway clearance in a postoperative client? a) Clear breath sounds b) Normal respiratory rate c) Use of accessory muscles and productive cough d) Oxygen saturation of 98% on room air Rationale: Use of accessory muscles and a productive cough indicate respiratory distress and ineffective airway clearance. 17.A client with hypertension is prescribed hydrochlorothiazide. What should the nurse monitor to prevent adverse effects? a) Blood glucose b) Potassium levels c) Serum calcium d) Hemoglobin levels Rationale: Hydrochlorothiazide is a potassium-wasting diuretic, so potassium levels must be monitored to prevent hypokalemia.
18.The nurse is assessing a client with suspected stroke. Which symptom is a priority to report immediately? a) Slurred speech b) Sudden weakness on one side of the body c) Headache lasting 2 hours d) Mild dizziness Rationale: Sudden unilateral weakness is an emergency sign indicating possible stroke and requires immediate action. 19.Which of the following symptoms is most consistent with hypoglycemia? a) Polyuria b) Sweating and confusion c) Dry mouth d) Fatigue Rationale: Sweating and confusion are classic symptoms of hypoglycemia due to neuroglycopenia and autonomic response. 20.A client with chronic liver disease is at risk for bleeding. Which laboratory test best indicates the client’s clotting status? a) Hemoglobin b) Platelet count c) Prothrombin time (PT) d) Serum albumin
a) Hypotension b) Bradycardia c) Hyperglycemia d) Weight loss Rationale: Prednisone can cause elevated blood glucose levels as a side effect. 24.Which symptom is most concerning in a client with pneumonia? a) Productive cough b) Mild fever c) Respiratory rate of 32 breaths per minute d) Fatigue Rationale: Tachypnea (RR > 30) indicates respiratory distress and requires immediate attention. 25.A nurse is caring for a client with a tracheostomy. What is the priority nursing intervention? a) Suctioning the airway regularly b) Providing oral hygiene c) Maintaining a patent airway d) Changing the tracheostomy ties daily Rationale: Maintaining a patent airway is the highest priority to ensure adequate ventilation and oxygenation.
26.Which of the following is an early sign of hypoxia? a) Cyanosis b) Bradypnea c) Restlessness d) Hypotension Rationale: Restlessness is an early sign of hypoxia caused by insufficient oxygen delivery to the brain. 27.The nurse is caring for a client with hyperthyroidism. Which finding is expected? a) Weight gain b) Heat intolerance c) Bradycardia d) Constipation Rationale: Clients with hyperthyroidism often have heat intolerance due to increased metabolism. 28.A client with Parkinson’s disease is experiencing difficulty swallowing. What is the nurse’s best intervention? a) Encourage large bites of food b) Provide thin liquids c) Provide thickened liquids and supervise meals d) Feed the client rapidly
b) Complete blood count c) Serum lithium levels d) Serum potassium Rationale: Lithium has a narrow therapeutic index; serum levels must be monitored to avoid toxicity. 32.A client is prescribed digoxin. Which symptom indicates digoxin toxicity? a) Hypertension b) Visual disturbances (yellow-green halos) c) Increased appetite d) Bradycardia Rationale: Visual disturbances, such as yellow-green halos, are early signs of digoxin toxicity. 33.Which dietary modification is recommended for a client with chronic kidney disease? a) High protein diet b) Restrict sodium and potassium intake c) High phosphorus diet d) Increase fluid intake Rationale: Restricting sodium and potassium helps reduce fluid retention and prevent hyperkalemia in kidney disease.
34.The nurse is caring for a client after a myocardial infarction. Which medication is important to administer to prevent further clot formation? a) Furosemide b) Nitroglycerin c) Aspirin d) Digoxin Rationale: Aspirin inhibits platelet aggregation and reduces the risk of additional clots after MI. 35.A client has a chest tube following a pneumothorax. Which finding requires immediate nursing intervention? a) Tidaling in the water seal chamber b) Gentle bubbling in the suction chamber c) Continuous bubbling in the water seal chamber d) Drainage of 50 mL per hour Rationale: Continuous bubbling in the water seal chamber indicates an air leak that requires immediate assessment and intervention. 36.A client with cirrhosis develops ascites. Which intervention should the nurse prioritize? a) Administer stool softeners b) Monitor abdominal girth daily c) Encourage high protein intake d) Promote bed rest
c) Tachycardia and hypotension d) Bradycardia Rationale: Tachycardia and hypotension indicate the body is compensating for decreased blood volume. 40.The nurse is caring for a client with a suspected gastrointestinal bleed. Which assessment finding is most important to report immediately? a) History of gastritis b) Black, tarry stools c) Mild abdominal discomfort d) Nausea Rationale: Black, tarry stools (melena) indicate upper GI bleeding and require urgent attention. 41.A client with asthma uses a metered-dose inhaler (MDI). Which instruction should the nurse give? a) Shake the inhaler after use b) Shake the inhaler before use c) Exhale after inhaling the medication d) Use the inhaler only when symptoms are severe Rationale: Shaking the inhaler before use ensures the medication is properly mixed for effective dosing.
42.Which clinical sign is most consistent with acute pancreatitis? a) Jaundice b) Severe epigastric pain radiating to the back c) Diarrhea d) Polyuria Rationale: Severe, radiating epigastric pain is a hallmark of acute pancreatitis. 43.A client is receiving total parenteral nutrition (TPN). Which complication should the nurse monitor for? a) Hypoglycemia b) Hyperkalemia c) Infection at the catheter site d) Hypertension Rationale: Infection at the catheter insertion site is a common risk associated with TPN therapy. 44.Which is the earliest clinical manifestation of shock? a) Hypotension b) Oliguria c) Tachycardia d) Cyanosis Rationale: Tachycardia is an early compensatory response to maintain cardiac output during shock.
c) Tachycardia d) Heat intolerance Rationale: Fatigue and cold intolerance are typical symptoms of hypothyroidism due to decreased metabolism. 48.A client receiving morphine reports difficulty breathing. What is the nurse’s priority action? a) Increase the morphine dose b) Assess respiratory rate and prepare to administer naloxone c) Encourage deep breathing exercises d) Notify the healthcare provider in 24 hours Rationale: Morphine can cause respiratory depression; assessing respiratory status and preparing naloxone is critical. 49.A client with anemia is prescribed ferrous sulfate. Which instruction should the nurse provide? a) Take with milk to reduce stomach upset b) Take with vitamin C to enhance absorption c) Take at bedtime d) Avoid fluids when taking medication Rationale: Vitamin C enhances the absorption of iron from ferrous sulfate supplements.
50.Which of the following is an expected finding in a client with chronic obstructive pulmonary disease (COPD)? a) Pink, warm skin b) Tachycardia c) Barrel chest d) Bradycardia Rationale: A barrel chest is a classic physical finding in COPD due to lung hyperinflation. 51.A client with a new colostomy asks how to prevent odor from the appliance. What is the best response? a) Use deodorant sprays inside the pouch b) Empty the pouch once a day c) Avoid foods that cause gas, such as beans and cabbage d) Clean the stoma with alcohol daily Rationale: Certain foods increase gas production and odor; avoiding these helps reduce unpleasant smells. 52.Which condition predisposes a client to developing pulmonary embolism? a) Asthma b) Pneumonia c) Deep vein thrombosis d) Chronic bronchitis
