ATI Med-Surg NUR 242 Galen College

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Sample questions from ATI Med-Surg NUR 242 Galen College

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.During a community wellness visit, an older adult reports becoming less steady when walking to the mailbox. Which assessment finding most strongly increases the risk for a fall?

   • A.The client takes several medications and reports dizziness when standing
   • B.The client reports waking once nightly to urinate
   • C.The client has age-related thinning of the skin
   • D.The client uses reading glasses for small print

   Rationale: Dizziness on standing while taking several medications raises concern for orthostatic hypotension and medication effects, both of which can impair balance and increase fall risk. Reading glasses may require environmental adjustments but do not indicate an immediate balance problem. Waking once nightly and skin thinning can affect safety or injury risk, but neither is as direct a cue for the reported unsteadiness. Assess orthostatic symptoms, medication effects, gait, and the home environment together.

2. 2.A client states, "My pain is still an 8 out of 10," 45 minutes after receiving the prescribed oral analgesic. The client is alert, has an unchanged respiratory rate, and is due to ambulate with physical therapy. What should the nurse do first?

   • A.Document that the medication was ineffective and discontinue it
   • B.Tell the client to wait until the next scheduled dose
   • C.Assist the client to ambulate before reassessing the pain
   • D.Reassess the pain characteristics and the client's response to the medication

   Rationale: Reassessment establishes whether the medication has had an effect and clarifies the pain's location, quality, and functional impact before further action. Waiting for the next dose without reassessing may leave significant pain untreated. Ambulation may be appropriate after pain is addressed, but proceeding without reassessment can impair participation and safety. The nurse should not discontinue a prescribed medication independently or conclude it is ineffective without evaluating the response.

3. 3.Refer to the client's chart. Which findings require prompt follow-up because they suggest an acute change rather than an expected age-related change? Select all that apply.

   • A.A decrease in oxygen saturation from 96% to 91% on room air
   • B.The client's report of new shortness of breath while resting
   • C.The client's report that hearing is reduced in a noisy room
   • D.New disorientation and difficulty following a one-step instruction
   • E.Dry, fragile skin noted during the admission assessment

   Rationale: New disorientation, a falling oxygen saturation, and new dyspnea at rest are acute changes that warrant prompt assessment and intervention; the chart shows these emerging by 1015. Dry, fragile skin is consistent with common age-related changes and is important for prevention but does not explain the acute deterioration. Reduced hearing in background noise can occur with aging and should prompt communication adjustments, not be treated as an acute change in this chart. Evaluate the changing findings together rather than attributing them to age.

4. 4.Which instruction is most appropriate for a client who is beginning a range-of-motion program after several days of reduced activity?

   • A.Keep the joints in one position between exercise sessions to avoid fatigue
   • B.Move each joint slowly through its available range and stop if sharp pain occurs
   • C.Perform only active exercises, even when weakness prevents full movement
   • D.Continue each movement through sharp pain to prevent stiffness

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, an older adult who usually walks to meals is newly reluctant to stand and has a small area of nonblanchable redness over the sacrum. Which action is the priority?

   • A.Massage the reddened area to increase circulation
   • B.Document the finding and reassess at the next weekly skin check
   • C.Relieve pressure from the sacrum and assess the skin and mobility status
   • D.Apply a heating pad over the sacrum for comfort

   Answer and rationale are in the full material.