ATI MEDICAL-SURGICAL RETAKE 2026/2027 | Graded A
Validation | 100% Correct Solutions | Pass Guaranteed - A+
Graded
[Section 1: Cardiovascular & Hematologic Disorders (Q1-18)]
Q1. A nurse is caring for a client with heart failure who has gained 3 pounds in 2 days.
Which action should the nurse take first?
A. Notify the provider immediately
B. Assess the client's ankles and sacrum for edema
C. Review the client's 24-hour intake and output record
D. Instruct the client to restrict sodium intake
Correct Answer: B. Assess the client's ankles and sacrum for edema [CORRECT]
Rationale: A 3-pound weight gain in 2 days indicates fluid retention. The nurse must first
assess for signs of fluid overload (peripheral and dependent edema) to determine
severity before notifying the provider or implementing interventions. Assessment is the
first step in the nursing process.
Q2. A client with heart failure is prescribed lisinopril, metoprolol, and furosemide. The
nurse should monitor for which adverse effect indicating that the furosemide dose may
need adjustment?
A. Bradycardia
B. Hypokalemia
C. Hyperglycemia
D. Constipation
Correct Answer: B. Hypokalemia [CORRECT]
,Rationale: Furosemide is a loop diuretic that causes potassium wasting through the
kidneys, leading to hypokalemia. The nurse must monitor potassium levels and assess
for muscle weakness, dysrhythmias, and fatigue. Bradycardia is associated with
beta-blockers; hyperglycemia and constipation are not primary concerns with
furosemide.
Q3. A client with atrial fibrillation is prescribed warfarin. The nurse knows that the
therapeutic INR range for this client is:
A. 0.5 to 1.5
B. 2.0 to 3.0
C. 3.5 to 4.5
D. 4.5 to 5.5
Correct Answer: B. 2.0 to 3.0 [CORRECT]
Rationale: The therapeutic INR for atrial fibrillation is 2.0 to 3.0. Values below 2.0
increase clot risk; values above 3.0 increase bleeding risk. INR ranges of 2.5 to 3.5 are
used for mechanical heart valves.
Q4. A nurse is providing discharge teaching to a client with heart failure. Which
statement by the client indicates a need for further instruction?
A. "I will weigh myself every morning before breakfast."
B. "I can drink up to 3 liters of fluid per day."
C. "I will take my medications exactly as prescribed."
D. "I will call my provider if I gain 2 pounds in one day."
Correct Answer: B. "I can drink up to 3 liters of fluid per day." [CORRECT]
Rationale: Clients with heart failure typically require fluid restriction of 1.5 to 2 liters per
day to prevent fluid overload. Three liters exceeds the recommended limit and could
,precipitate exacerbation. Daily weights, medication adherence, and reporting rapid
weight gain are all correct self-management strategies.
Q5. A client with deep vein thrombosis (DVT) is receiving heparin therapy. The nurse
should monitor which laboratory value to assess therapeutic effectiveness?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Prothrombin time (PT)
D. Complete blood count (CBC)
Correct Answer: B. Activated partial thromboplastin time (aPTT) [CORRECT]
Rationale: Heparin therapy is monitored using aPTT, with a therapeutic range typically
1.5 to 2.5 times the control value. PT/INR monitors warfarin. Platelet count monitors for
heparin-induced thrombocytopenia (HIT), which is an adverse effect, not a measure of
therapeutic effectiveness.
Q6. A nurse is caring for a client who had a myocardial infarction 24 hours ago. The
client reports sudden onset of dyspnea, tachycardia, and restlessness. Which
complication should the nurse suspect first?
A. Cardiac tamponade
B. Pulmonary embolism
C. Cardiogenic shock
D. Ventricular aneurysm
Correct Answer: B. Pulmonary embolism [CORRECT]
Rationale: Sudden dyspnea, tachycardia, and restlessness in a post-MI client are classic
signs of pulmonary embolism, a complication of immobility and venous stasis. Cardiac
tamponade presents with Beck's triad (hypotension, JVD, muffled heart sounds).
Cardiogenic shock develops gradually with hypotension and oliguria.
, Q7. A client with heart failure has a serum potassium level of 3.1 mEq/L. Which finding
should the nurse report to the provider immediately?
A. Flat T waves on ECG
B. Muscle weakness
C. Constipation
D. Polyuria
Correct Answer: A. Flat T waves on ECG [CORRECT]
Rationale: Flat T waves on ECG indicate cardiac involvement from hypokalemia (normal
K+ 3.5-5.0 mEq/L), which can progress to life-threatening dysrhythmias. While muscle
weakness and constipation are symptoms of hypokalemia, ECG changes represent the
most urgent priority due to risk of fatal arrhythmias.
Q8. A nurse is preparing to administer digoxin to a client with heart failure. Before giving
the medication, the nurse should check the client's:
A. Blood pressure
B. Apical pulse rate
C. Respiratory rate
D. Oxygen saturation
Correct Answer: B. Apical pulse rate [CORRECT]
Rationale: Digoxin slows the heart rate and can cause bradycardia. Hold the dose if
apical pulse is below 60 bpm (or per agency protocol) and notify the provider. While
blood pressure and oxygen saturation are important, apical pulse is the specific
assessment required before digoxin administration.
Q9. A client with anemia has a hemoglobin of 7.2 g/dL. The nurse should expect the
provider to order:
A. Oral iron supplements
B. Blood transfusion
Validation | 100% Correct Solutions | Pass Guaranteed - A+
Graded
[Section 1: Cardiovascular & Hematologic Disorders (Q1-18)]
Q1. A nurse is caring for a client with heart failure who has gained 3 pounds in 2 days.
Which action should the nurse take first?
A. Notify the provider immediately
B. Assess the client's ankles and sacrum for edema
C. Review the client's 24-hour intake and output record
D. Instruct the client to restrict sodium intake
Correct Answer: B. Assess the client's ankles and sacrum for edema [CORRECT]
Rationale: A 3-pound weight gain in 2 days indicates fluid retention. The nurse must first
assess for signs of fluid overload (peripheral and dependent edema) to determine
severity before notifying the provider or implementing interventions. Assessment is the
first step in the nursing process.
Q2. A client with heart failure is prescribed lisinopril, metoprolol, and furosemide. The
nurse should monitor for which adverse effect indicating that the furosemide dose may
need adjustment?
A. Bradycardia
B. Hypokalemia
C. Hyperglycemia
D. Constipation
Correct Answer: B. Hypokalemia [CORRECT]
,Rationale: Furosemide is a loop diuretic that causes potassium wasting through the
kidneys, leading to hypokalemia. The nurse must monitor potassium levels and assess
for muscle weakness, dysrhythmias, and fatigue. Bradycardia is associated with
beta-blockers; hyperglycemia and constipation are not primary concerns with
furosemide.
Q3. A client with atrial fibrillation is prescribed warfarin. The nurse knows that the
therapeutic INR range for this client is:
A. 0.5 to 1.5
B. 2.0 to 3.0
C. 3.5 to 4.5
D. 4.5 to 5.5
Correct Answer: B. 2.0 to 3.0 [CORRECT]
Rationale: The therapeutic INR for atrial fibrillation is 2.0 to 3.0. Values below 2.0
increase clot risk; values above 3.0 increase bleeding risk. INR ranges of 2.5 to 3.5 are
used for mechanical heart valves.
Q4. A nurse is providing discharge teaching to a client with heart failure. Which
statement by the client indicates a need for further instruction?
A. "I will weigh myself every morning before breakfast."
B. "I can drink up to 3 liters of fluid per day."
C. "I will take my medications exactly as prescribed."
D. "I will call my provider if I gain 2 pounds in one day."
Correct Answer: B. "I can drink up to 3 liters of fluid per day." [CORRECT]
Rationale: Clients with heart failure typically require fluid restriction of 1.5 to 2 liters per
day to prevent fluid overload. Three liters exceeds the recommended limit and could
,precipitate exacerbation. Daily weights, medication adherence, and reporting rapid
weight gain are all correct self-management strategies.
Q5. A client with deep vein thrombosis (DVT) is receiving heparin therapy. The nurse
should monitor which laboratory value to assess therapeutic effectiveness?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Prothrombin time (PT)
D. Complete blood count (CBC)
Correct Answer: B. Activated partial thromboplastin time (aPTT) [CORRECT]
Rationale: Heparin therapy is monitored using aPTT, with a therapeutic range typically
1.5 to 2.5 times the control value. PT/INR monitors warfarin. Platelet count monitors for
heparin-induced thrombocytopenia (HIT), which is an adverse effect, not a measure of
therapeutic effectiveness.
Q6. A nurse is caring for a client who had a myocardial infarction 24 hours ago. The
client reports sudden onset of dyspnea, tachycardia, and restlessness. Which
complication should the nurse suspect first?
A. Cardiac tamponade
B. Pulmonary embolism
C. Cardiogenic shock
D. Ventricular aneurysm
Correct Answer: B. Pulmonary embolism [CORRECT]
Rationale: Sudden dyspnea, tachycardia, and restlessness in a post-MI client are classic
signs of pulmonary embolism, a complication of immobility and venous stasis. Cardiac
tamponade presents with Beck's triad (hypotension, JVD, muffled heart sounds).
Cardiogenic shock develops gradually with hypotension and oliguria.
, Q7. A client with heart failure has a serum potassium level of 3.1 mEq/L. Which finding
should the nurse report to the provider immediately?
A. Flat T waves on ECG
B. Muscle weakness
C. Constipation
D. Polyuria
Correct Answer: A. Flat T waves on ECG [CORRECT]
Rationale: Flat T waves on ECG indicate cardiac involvement from hypokalemia (normal
K+ 3.5-5.0 mEq/L), which can progress to life-threatening dysrhythmias. While muscle
weakness and constipation are symptoms of hypokalemia, ECG changes represent the
most urgent priority due to risk of fatal arrhythmias.
Q8. A nurse is preparing to administer digoxin to a client with heart failure. Before giving
the medication, the nurse should check the client's:
A. Blood pressure
B. Apical pulse rate
C. Respiratory rate
D. Oxygen saturation
Correct Answer: B. Apical pulse rate [CORRECT]
Rationale: Digoxin slows the heart rate and can cause bradycardia. Hold the dose if
apical pulse is below 60 bpm (or per agency protocol) and notify the provider. While
blood pressure and oxygen saturation are important, apical pulse is the specific
assessment required before digoxin administration.
Q9. A client with anemia has a hemoglobin of 7.2 g/dL. The nurse should expect the
provider to order:
A. Oral iron supplements
B. Blood transfusion
