ATI RN Adult Medical-Surgical (Med-Surg) Advanced Clinical
Judgment Examination v3.1
Comprehensive 100-Question Test Bank with Evidence-Based
Rationales
Cardiovascular System (Questions 1–20)
Question 1
A 68-year-old male client with a history of hypertension and type 2 diabetes presents to the
emergency department with substernal chest pressure radiating to the jaw, accompanied by nausea
and diaphoresis for the past 45 minutes. The initial 12-lead ECG shows 2-mm ST-segment elevations in
leads V1–V4 with reciprocal depression in leads II, III, and aVF. The client's blood pressure is 142/88
mm Hg, heart rate 96/min, respiratory rate 20/min, and SpO₂ 94% on room air. The provider has
ordered aspirin 324 mg chewed, nitroglycerin 0.4 mg sublingual, and oxygen 2 L/min via nasal cannula.
After administering these interventions, the client's chest pain decreases from 8/10 to 4/10. Which
action should the nurse take next?
A. Prepare the client for immediate percutaneous coronary intervention (PCI)
B. Administer IV morphine sulfate 2 mg
C. Administer IV heparin bolus as prescribed
D. Repeat the 12-lead ECG to assess for dynamic changes
Correct Answer: C
Rationale: This client is experiencing an acute ST-elevation myocardial infarction (STEMI) as evidenced
by ST elevations in V1–V4 (anteroseptal wall involvement). The priority treatment for STEMI is rapid
reperfusion therapy (PCI or fibrinolytics). However, the question asks for the next action after initial
interventions. Heparin administration is a critical component of STEMI management to prevent further
thrombosis and is typically initiated immediately after aspirin. While morphine may be given for
persistent pain, the pain has improved. Repeating the ECG is appropriate but not the immediate
,priority. Preparation for PCI is essential but occurs concurrently with medication administration;
heparin should be administered without delay while arrangements for PCI are made.
Question 2
A 74-year-old female client with chronic heart failure (HF) with reduced ejection fraction (HFrEF) is
admitted with acute decompensated heart failure. Her medications include lisinopril 20 mg daily,
carvedilol 25 mg twice daily, furosemide 40 mg daily, and spironolactone 25 mg daily. On admission,
her blood pressure is 158/92 mm Hg, heart rate 102/min, respiratory rate 28/min, SpO₂ 89% on room
air, and she has 3+ pitting edema in the lower extremities, jugular venous distension, and crackles
auscultated to the mid-lung fields bilaterally. The provider orders IV furosemide 80 mg push and
oxygen 4 L/min via nasal cannula. One hour after administration, the client's urinary output is 300 mL,
blood pressure is 146/88 mm Hg, and she reports less dyspnea. Which assessment finding indicates a
potential adverse effect of the furosemide that requires immediate intervention?
A. Serum potassium level of 3.2 mEq/L
B. Serum creatinine increase from 1.2 to 1.6 mg/dL
C. Client reports mild dizziness when standing
D. Urine output of 300 mL in the first hour
Correct Answer: A
Rationale: Furosemide is a loop diuretic that promotes excretion of potassium, leading to
hypokalemia. A serum potassium of 3.2 mEq/L is significantly low and places the client at risk for
cardiac arrhythmias, especially given the concurrent use of digoxin (not mentioned but common in
HFrEF) and the presence of underlying cardiac disease. The combination of furosemide with
spironolactone (a potassium-sparing diuretic) should mitigate potassium loss, but hypokalemia can
still occur. Serum creatinine increase (prerenal azotemia from diuresis) should be monitored but is not
an immediate life-threatening finding. Mild dizziness is expected with diuresis and should be assessed
further. A urine output of 300 mL in the first hour indicates a good response to the diuretic.
Question 3
A 62-year-old male client with a history of atrial fibrillation and mechanical mitral valve replacement is
admitted with acute-onset right-sided weakness, aphasia, and facial droop. His last known well time
,was 2.5 hours ago. His current medications include warfarin 7.5 mg daily, amiodarone 200 mg daily,
and metoprolol 50 mg twice daily. His INR on admission is 3.2. The emergency department provider is
considering IV alteplase (tPA) for acute ischemic stroke. Which action should the nurse anticipate
based on the client's current status?
A. Proceed with IV alteplase administration as the INR is within the therapeutic range
B. Hold alteplase and consider mechanical thrombectomy instead
C. Administer vitamin K to reverse the warfarin effect before alteplase
D. Administer IV alteplase after platelet transfusion
Correct Answer: B
Rationale: This client has a mechanical heart valve and is on warfarin with a therapeutic INR of 3.2. The
use of IV alteplase is contraindicated in clients with an INR >1.7, active bleeding, or a history of recent
major surgery. The presence of a mechanical valve also increases the risk of thromboembolic
complications but does not preclude alteplase if the INR were <1.7. However, in this case, the INR of
3.2 exceeds the safe threshold for alteplase administration. Mechanical thrombectomy is a viable
alternative for large vessel occlusion and may be considered in clients with contraindications to
thrombolytics. Reversing warfarin with vitamin K would require time and would not be appropriate
before thrombolysis. Platelet transfusion is not indicated.
Question 4
A 55-year-old female client with no significant medical history presents to the clinic with complaints of
progressive shortness of breath, fatigue, and palpitations over the past 3 months. Physical examination
reveals a mid-systolic click followed by a late systolic murmur at the apex, which increases in intensity
with squatting. The nurse suspects which cardiac valvular disorder?
A. Aortic stenosis
B. Mitral valve prolapse
C. Mitral stenosis
D. Tricuspid regurgitation
Correct Answer: B
Rationale: Mitral valve prolapse (MVP) is characterized by a mid-systolic click followed by a late
systolic murmur best heard at the apex. The murmur increases with squatting (increased preload) and
, decreases with standing or Valsalva maneuver (decreased preload). Aortic stenosis presents with a
systolic ejection murmur at the right upper sternal border. Mitral stenosis presents with a diastolic
rumble at the apex. Tricuspid regurgitation presents with a systolic murmur at the left lower sternal
border.
Question 5
A 72-year-old male client is 6 hours post-operative following a coronary artery bypass graft (CABG)
surgery. His vital signs are blood pressure 94/62 mm Hg, heart rate 112/min, respiratory rate 22/min,
and temperature 37.2°C (99°F). His chest tube drainage has increased from 50 mL/hr to 150 mL/hr over
the past hour, and the drainage is bright red with visible clots. The nurse notifies the provider and
prepares for which potential intervention?
A. Administration of protamine sulfate
B. Administration of vitamin K
C. Return to the operating room for exploration
D. Administration of IV crystalloid fluids only
Correct Answer: A
Rationale: The client is exhibiting signs of postoperative bleeding with increased chest tube output
(150 mL/hr), bright red drainage with clots, and hemodynamic instability (hypotension, tachycardia).
While the client may require fluid resuscitation and possible return to the operating room,
the immediate intervention to consider is reversal of heparin if it was used during surgery. Protamine
sulfate is the antidote for heparin and may be administered if bleeding is related to heparin effect.
Vitamin K reverses warfarin, which is not typically used immediately post-CABG. While fluid
resuscitation and surgical exploration may be necessary, the nurse should anticipate protamine
administration as the first-line medical intervention for heparin-related bleeding.
Question 6
A 58-year-old male client with a history of peripheral artery disease (PAD) presents with a non-healing
ulcer on the lateral aspect of his right foot. The ulcer is pale, dry, and has well-defined borders. The
right foot is cool to the touch, and the dorsalis pedis pulse is absent. The client reports pain in the
Judgment Examination v3.1
Comprehensive 100-Question Test Bank with Evidence-Based
Rationales
Cardiovascular System (Questions 1–20)
Question 1
A 68-year-old male client with a history of hypertension and type 2 diabetes presents to the
emergency department with substernal chest pressure radiating to the jaw, accompanied by nausea
and diaphoresis for the past 45 minutes. The initial 12-lead ECG shows 2-mm ST-segment elevations in
leads V1–V4 with reciprocal depression in leads II, III, and aVF. The client's blood pressure is 142/88
mm Hg, heart rate 96/min, respiratory rate 20/min, and SpO₂ 94% on room air. The provider has
ordered aspirin 324 mg chewed, nitroglycerin 0.4 mg sublingual, and oxygen 2 L/min via nasal cannula.
After administering these interventions, the client's chest pain decreases from 8/10 to 4/10. Which
action should the nurse take next?
A. Prepare the client for immediate percutaneous coronary intervention (PCI)
B. Administer IV morphine sulfate 2 mg
C. Administer IV heparin bolus as prescribed
D. Repeat the 12-lead ECG to assess for dynamic changes
Correct Answer: C
Rationale: This client is experiencing an acute ST-elevation myocardial infarction (STEMI) as evidenced
by ST elevations in V1–V4 (anteroseptal wall involvement). The priority treatment for STEMI is rapid
reperfusion therapy (PCI or fibrinolytics). However, the question asks for the next action after initial
interventions. Heparin administration is a critical component of STEMI management to prevent further
thrombosis and is typically initiated immediately after aspirin. While morphine may be given for
persistent pain, the pain has improved. Repeating the ECG is appropriate but not the immediate
,priority. Preparation for PCI is essential but occurs concurrently with medication administration;
heparin should be administered without delay while arrangements for PCI are made.
Question 2
A 74-year-old female client with chronic heart failure (HF) with reduced ejection fraction (HFrEF) is
admitted with acute decompensated heart failure. Her medications include lisinopril 20 mg daily,
carvedilol 25 mg twice daily, furosemide 40 mg daily, and spironolactone 25 mg daily. On admission,
her blood pressure is 158/92 mm Hg, heart rate 102/min, respiratory rate 28/min, SpO₂ 89% on room
air, and she has 3+ pitting edema in the lower extremities, jugular venous distension, and crackles
auscultated to the mid-lung fields bilaterally. The provider orders IV furosemide 80 mg push and
oxygen 4 L/min via nasal cannula. One hour after administration, the client's urinary output is 300 mL,
blood pressure is 146/88 mm Hg, and she reports less dyspnea. Which assessment finding indicates a
potential adverse effect of the furosemide that requires immediate intervention?
A. Serum potassium level of 3.2 mEq/L
B. Serum creatinine increase from 1.2 to 1.6 mg/dL
C. Client reports mild dizziness when standing
D. Urine output of 300 mL in the first hour
Correct Answer: A
Rationale: Furosemide is a loop diuretic that promotes excretion of potassium, leading to
hypokalemia. A serum potassium of 3.2 mEq/L is significantly low and places the client at risk for
cardiac arrhythmias, especially given the concurrent use of digoxin (not mentioned but common in
HFrEF) and the presence of underlying cardiac disease. The combination of furosemide with
spironolactone (a potassium-sparing diuretic) should mitigate potassium loss, but hypokalemia can
still occur. Serum creatinine increase (prerenal azotemia from diuresis) should be monitored but is not
an immediate life-threatening finding. Mild dizziness is expected with diuresis and should be assessed
further. A urine output of 300 mL in the first hour indicates a good response to the diuretic.
Question 3
A 62-year-old male client with a history of atrial fibrillation and mechanical mitral valve replacement is
admitted with acute-onset right-sided weakness, aphasia, and facial droop. His last known well time
,was 2.5 hours ago. His current medications include warfarin 7.5 mg daily, amiodarone 200 mg daily,
and metoprolol 50 mg twice daily. His INR on admission is 3.2. The emergency department provider is
considering IV alteplase (tPA) for acute ischemic stroke. Which action should the nurse anticipate
based on the client's current status?
A. Proceed with IV alteplase administration as the INR is within the therapeutic range
B. Hold alteplase and consider mechanical thrombectomy instead
C. Administer vitamin K to reverse the warfarin effect before alteplase
D. Administer IV alteplase after platelet transfusion
Correct Answer: B
Rationale: This client has a mechanical heart valve and is on warfarin with a therapeutic INR of 3.2. The
use of IV alteplase is contraindicated in clients with an INR >1.7, active bleeding, or a history of recent
major surgery. The presence of a mechanical valve also increases the risk of thromboembolic
complications but does not preclude alteplase if the INR were <1.7. However, in this case, the INR of
3.2 exceeds the safe threshold for alteplase administration. Mechanical thrombectomy is a viable
alternative for large vessel occlusion and may be considered in clients with contraindications to
thrombolytics. Reversing warfarin with vitamin K would require time and would not be appropriate
before thrombolysis. Platelet transfusion is not indicated.
Question 4
A 55-year-old female client with no significant medical history presents to the clinic with complaints of
progressive shortness of breath, fatigue, and palpitations over the past 3 months. Physical examination
reveals a mid-systolic click followed by a late systolic murmur at the apex, which increases in intensity
with squatting. The nurse suspects which cardiac valvular disorder?
A. Aortic stenosis
B. Mitral valve prolapse
C. Mitral stenosis
D. Tricuspid regurgitation
Correct Answer: B
Rationale: Mitral valve prolapse (MVP) is characterized by a mid-systolic click followed by a late
systolic murmur best heard at the apex. The murmur increases with squatting (increased preload) and
, decreases with standing or Valsalva maneuver (decreased preload). Aortic stenosis presents with a
systolic ejection murmur at the right upper sternal border. Mitral stenosis presents with a diastolic
rumble at the apex. Tricuspid regurgitation presents with a systolic murmur at the left lower sternal
border.
Question 5
A 72-year-old male client is 6 hours post-operative following a coronary artery bypass graft (CABG)
surgery. His vital signs are blood pressure 94/62 mm Hg, heart rate 112/min, respiratory rate 22/min,
and temperature 37.2°C (99°F). His chest tube drainage has increased from 50 mL/hr to 150 mL/hr over
the past hour, and the drainage is bright red with visible clots. The nurse notifies the provider and
prepares for which potential intervention?
A. Administration of protamine sulfate
B. Administration of vitamin K
C. Return to the operating room for exploration
D. Administration of IV crystalloid fluids only
Correct Answer: A
Rationale: The client is exhibiting signs of postoperative bleeding with increased chest tube output
(150 mL/hr), bright red drainage with clots, and hemodynamic instability (hypotension, tachycardia).
While the client may require fluid resuscitation and possible return to the operating room,
the immediate intervention to consider is reversal of heparin if it was used during surgery. Protamine
sulfate is the antidote for heparin and may be administered if bleeding is related to heparin effect.
Vitamin K reverses warfarin, which is not typically used immediately post-CABG. While fluid
resuscitation and surgical exploration may be necessary, the nurse should anticipate protamine
administration as the first-line medical intervention for heparin-related bleeding.
Question 6
A 58-year-old male client with a history of peripheral artery disease (PAD) presents with a non-healing
ulcer on the lateral aspect of his right foot. The ulcer is pale, dry, and has well-defined borders. The
right foot is cool to the touch, and the dorsalis pedis pulse is absent. The client reports pain in the
