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Ace Your Test with ATI Anderson MS II. Actual Questions and Solutions - Full Set

Free ATI Anderson MS II. Questions

1.

A nurse is caring for a client who is at risk for shock. Which of the following findings should the nurse expect?

  • Increased urine output

  • Hyperactive bowel sounds

  • Bradycardia

  • Hypotension

Explanation

Explanation
Correct Answer: D) Hypotension.
Hypotension is a hallmark sign of shock, resulting from inadequate circulating blood volume or decreased cardiac output that fails to maintain adequate perfusion pressure. As shock progresses, urine output decreases (not increases) due to poor renal perfusion, bowel sounds diminish rather than become hyperactive, and the heart rate increases (tachycardia), not decreases, as a compensatory response. Hypotension is the most consistent and expected finding across all types of shock.
2.

A nurse is reviewing the anatomy of the heart chambers and valves with a patient diagnosed with valvular heart disease. Based on your knowledge of cardiac anatomy and function, which of the following pairings between heart chambers and their correct names are accurate? (Select All that Apply.)

  • Right ventricle - pumps deoxygenated blood into the pulmonary artery through the pulmonic valve

  • Left atrium - receives oxygenated blood from the pulmonary veins

  • Right atrium - receives deoxygenated blood from the body via the superior and inferior vena cava

  • Tricuspid valve - located between the right atrium and right ventricle

  • Left ventricle - pumps oxygenated blood into the pulmonary artery

  • Aorta - receives deoxygenated blood from the right ventricle

Explanation

Explanation
The right ventricle pumps deoxygenated blood through the pulmonic valve into the pulmonary artery to the lungs. The left atrium receives freshly oxygenated blood returning from the lungs via the pulmonary veins. The right atrium collects deoxygenated blood from the body through the superior and inferior vena cava. The tricuspid valve is correctly positioned between the right atrium and right ventricle. The left ventricle pumps oxygenated blood into the aorta — not the pulmonary artery. The aorta carries oxygenated blood from the left ventricle — not deoxygenated blood from the right ventricle.
3.

A nurse is reinforcing teaching to a female client who has acute cystitis and is to start therapy with phenazopyridine (Pyridium). Which of the following information should the nurse give to the client?

  • "Take the medication on an empty stomach."

  • "Use birth control while taking this medication to prevent pregnancy."

  • "Finish the medication in order to resolve the infection."

  • "This medication will turn your urine bright orange/red."

Explanation

Explanation
Correct Answer: D) "This medication will turn your urine bright orange/red."
Phenazopyridine (Pyridium) is a urinary analgesic that relieves the burning, urgency, and discomfort associated with cystitis. A critical teaching point is that it causes urine to turn a bright orange or red color, which can be alarming to patients if not anticipated. It should be taken with food to reduce gastric upset, not on an empty stomach. It is not an antibiotic and does not resolve the infection, so telling the patient to finish it to cure the infection is incorrect. It has no interaction with birth control.
4.

A nurse is reinforcing teaching with a client who has received treatment for kidney stones. The nurse should remind the client to increase intake of which of the following?

  • Tea

  • Protein

  • Sodium

  • Water

Explanation

Explanation
Correct Answer: D) Water.
Increasing water intake is the most important dietary measure to prevent recurrence of kidney stones. Adequate hydration dilutes the urine, reducing the concentration of stone-forming minerals such as calcium, oxalate, and uric acid, thereby decreasing the likelihood of crystal formation and aggregation. Tea contains oxalates which can contribute to stone formation, and high protein and sodium intake increase urinary calcium excretion, all of which promote kidney stone development.
5.

A nurse is assessing a patient with chronic venous insufficiency. Where are the valves located in the vascular system outside of the heart, and what is their primary function?

  • In the veins, to prevent backflow of blood and ensure unidirectional flow toward the heart.

  • In the arteries, to help withstand high pressure and maintain arterial blood flow.

  • In the capillaries, to regulate the exchange of nutrients and waste products.

  • In the lymphatic vessels, to manage the flow of lymph fluid.

Explanation

Explanation
Correct Answer: A) In the veins, to prevent backflow of blood and ensure unidirectional flow toward the heart.
Veins contain one-way valves that prevent the retrograde (backward) flow of blood and ensure blood moves unidirectionally toward the heart. This is especially critical in the lower extremities where blood must flow against gravity. In chronic venous insufficiency, these valves become damaged or incompetent, allowing blood to pool in the veins, leading to edema, varicosities, and skin changes. Arteries do not contain valves — their thick muscular walls and the propulsive force of the heart maintain directional arterial flow. Capillaries have no valves; they facilitate nutrient and gas exchange. Lymphatic vessels do have valves, but they manage lymph fluid, not venous blood return.
6.

A pediatric patient with chronic liver disease is found to have prolonged bleeding times and low platelet counts during assessment. Which role of the liver should the nurse evaluate to explain these hematologic abnormalities?

  • The liver stores excess iron and releases it immediately to increase platelet production when needed.

  • The liver produces clotting factors essential for hemostasis, and its dysfunction can impair clot formation.

  • The liver produces erythropoietin, which stimulates white blood cell production in the bone marrow.

  • The liver filters aged red blood cells, preventing anemia caused by excess breakdown of healthy cells.

Explanation

Explanation
Correct Answer: B) The liver produces clotting factors essential for hemostasis, and its dysfunction can impair clot formation.
The liver is responsible for synthesizing the majority of coagulation factors, including factors I (fibrinogen), II (prothrombin), V, VII, IX, and X. When the liver is damaged by chronic disease, production of these clotting factors is impaired, leading to prolonged bleeding times (elevated PT/INR). Additionally, portal hypertension from chronic liver disease causes splenic sequestration of platelets, resulting in thrombocytopenia. Iron storage supports red blood cell production, not platelet production. Erythropoietin is produced by the kidneys, not the liver. Filtering aged red blood cells is a function of the spleen, not the liver.
7.

A nurse is assisting with the care of a client who is in hemorrhagic shock and has a prescription for packed red blood cells. Which type of blood can be administered to the client while awaiting blood from a type and cross-match?

  • Type B

  • Type A

  • Type AB

  • Type O

Explanation

Explanation
Correct Answer: D) Type O.
Type O negative blood is the universal donor blood type, meaning it can be safely transfused to any patient regardless of their blood type because it lacks A, B, and Rh antigens on the red blood cells. In emergency situations such as hemorrhagic shock where there is no time to wait for a type and cross-match, Type O negative packed red blood cells are administered to prevent life-threatening blood loss while compatibility testing is completed.
8.

An older adult patient exhibits decreased antidiuretic hormone (ADH) responsiveness due to age-related endocrine changes. Based on this alteration, which complication is the patient most at risk for?

  • Dehydration.

  • Hyponatremia.

  • Fluid overload.

  • Hypertension.

Explanation

Explanation
Correct Answer: A) Dehydration.
ADH (vasopressin) acts on the kidneys to promote water reabsorption and concentrate urine. When ADH responsiveness is decreased, the kidneys are unable to adequately reabsorb water, resulting in increased urine output and loss of free water. This places the older adult at significant risk for dehydration. Hyponatremia and fluid overload would result from excess ADH activity (SIADH), the opposite scenario. Older adults are particularly vulnerable because they also have a diminished thirst response, compounding the dehydration risk.
9.

A nurse is caring for a patient with an irregular heart rhythm and is reviewing the cardiac conduction system. How should the nurse explain the function and nickname of the sinoatrial (SA) node to the patient?

  • The SA node delays electrical impulses to allow ventricular filling before contraction.

  • The SA node is the heart's primary pacemaker that initiates electrical impulses to regulate heartbeat.

  • The SA node transmits impulses to the Purkinje fibers to directly cause ventricular contraction.

  • The SA node functions as the secondary pacemaker and only activates when the AV node fails.

Explanation

Explanation
Correct Answer: B) The SA node is the heart's primary pacemaker that initiates electrical impulses to regulate heartbeat.
The sinoatrial (SA) node, located in the right atrium, is known as the heart's natural pacemaker. It spontaneously generates electrical impulses at a rate of 60–100 beats per minute, which spread through the atria causing atrial contraction, then travel to the AV node, bundle of His, bundle branches, and Purkinje fibers to stimulate ventricular contraction. In patients with irregular heart rhythms, dysfunction of the SA node disrupts this organized electrical sequence. Delaying impulses to allow ventricular filling is the role of the AV node, not the SA node. The SA node does not directly transmit to Purkinje fibers. It is the primary pacemaker, not the secondary — the AV node serves as the backup pacemaker.
10.

A nurse is caring for a patient with respiratory distress and observes the use of accessory muscles during inspiration. Based on the understanding of respiratory mechanics, what is the primary physiological mechanism that facilitates air movement into the lungs during inspiration?

  • Passive recoil of lung tissues expanding the thoracic cavity and drawing air in.

  • Relaxation of the diaphragm leading to increased intrathoracic pressure and passive air movement into the lungs.

  • Contraction of the diaphragm causing it to move downward and expansion of the chest cavity creating negative intrathoracic pressure.

  • Contraction of the abdominal muscles to push the diaphragm upward, forcing air into the lungs.

Explanation

Explanation
Correct Answer: C) Contraction of the diaphragm causing it to move downward and expansion of the chest cavity creating negative intrathoracic pressure.
During normal inspiration, the diaphragm contracts and moves downward, increasing the vertical dimension of the thoracic cavity. This expansion creates a negative intrathoracic pressure (below atmospheric pressure), which draws air into the lungs. In respiratory distress, accessory muscles (sternocleidomastoid, scalenes) are recruited to further expand the chest cavity when the diaphragm alone is insufficient. Passive recoil occurs during expiration, not inspiration. Diaphragm relaxation increases intrathoracic pressure and facilitates expiration. Abdominal muscle contraction pushes the diaphragm up, aiding forced expiration.

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