ATI RN Adult Medical-Surgical
Nursing: The Ultimate 100-Question
Practice Exam with Comprehensive
Rationales
Cardiovascular System
1. A client with heart failure reports dyspnea, orthopnea, and
a weight gain of 5 lb in 2 days. What is the nurse's priority
action?
A) Administer furosemide IV
B) Place the client in high-Fowler's position
C) Obtain a stat chest x-ray
D) Auscultate breath sounds
Answer B) Place the client in high-Fowler's position
Rationale: High-Fowler's position reduces venous return and
improves ventilation, which is the immediate priority before other
interventions. The ABCs (Airway, Breathing, Circulation) guide
prioritization — positioning to optimize breathing comes before
medication administration or diagnostic tests.
,2. A client with heart failure is prescribed furosemide. Which
assessment finding indicates the medication is effective?
A) Weight gain of 2 lbs in 24 hours
B) Clear lung sounds
C) Blood pressure 150/90 mmHg
D) 2+ pitting edema in lower extremities
Answer B) Clear lung sounds
Rationale: Furosemide is a loop diuretic that reduces fluid
overload. Clear lung sounds indicate decreased pulmonary
congestion. Weight loss (not gain), reduced edema, and
controlled blood pressure are also signs of effectiveness.
3. A client on digoxin reports nausea, vomiting, and sees
yellow halos around lights. What is the priority action?
A) Administer an antiemetic
B) Hold the digoxin and check serum digoxin level
C) Give the digoxin with food to reduce GI upset
D) Reassure the client this is a normal side effect
Answer B) Hold the digoxin and check serum digoxin level
Rationale: Nausea, vomiting, and visual disturbances
(yellow/green halos) are classic signs of digoxin toxicity. The
medication should be held, and the provider notified immediately.
,4. A client with atrial fibrillation is prescribed warfarin. The
INR is 4.5. What action should the nurse take?
A) Administer the next dose as scheduled
B) Hold the dose and notify the provider
C) Administer vitamin K 10 mg IM
D) Increase the warfarin dose
Answer B) Hold the dose and notify the provider
Rationale: The therapeutic INR range for atrial fibrillation on
warfarin is 2.0–3.0. An INR of 4.5 is above the therapeutic range
and indicates increased bleeding risk. The dose should be held
and the provider notified.
5. A client is receiving IV heparin. The aPTT is 120 seconds,
and the control is 30 seconds. Which action should the nurse
take?
A) Increase the heparin infusion rate
B) Prepare to administer protamine sulfate
C) Continue the infusion and recheck in 4 hours
D) Administer vitamin K
Answer B) Prepare to administer protamine sulfate
Rationale: The therapeutic aPTT range for heparin is 1.5–2.5 times
the control (45–75 seconds). An aPTT of 120 seconds indicates
excessive anticoagulation with high bleeding risk. Protamine
, sulfate is the specific antidote that reverses heparin's effects.
Vitamin K reverses warfarin, not heparin.
6. Which adverse effects should the nurse monitor for in a
client receiving heparin? (Select all that apply)
A) Bleeding gums
B) Bruising
C) Hypertension
D) Thrombocytopenia
E) Hyperkalemia
Answer A, B, D
Rationale: Heparin can cause bleeding (bleeding gums, bruising)
and heparin-induced thrombocytopenia (HIT). It does not typically
cause hypertension or hyperkalemia.
7. A client with hypertension is prescribed lisinopril. Which
finding requires immediate intervention?
A) Dry cough
B) Serum potassium 5.8 mEq/L
C) Dizziness when standing
D) Angioedema of the lips and tongue
Answer D) Angioedema of the lips and tongue
Nursing: The Ultimate 100-Question
Practice Exam with Comprehensive
Rationales
Cardiovascular System
1. A client with heart failure reports dyspnea, orthopnea, and
a weight gain of 5 lb in 2 days. What is the nurse's priority
action?
A) Administer furosemide IV
B) Place the client in high-Fowler's position
C) Obtain a stat chest x-ray
D) Auscultate breath sounds
Answer B) Place the client in high-Fowler's position
Rationale: High-Fowler's position reduces venous return and
improves ventilation, which is the immediate priority before other
interventions. The ABCs (Airway, Breathing, Circulation) guide
prioritization — positioning to optimize breathing comes before
medication administration or diagnostic tests.
,2. A client with heart failure is prescribed furosemide. Which
assessment finding indicates the medication is effective?
A) Weight gain of 2 lbs in 24 hours
B) Clear lung sounds
C) Blood pressure 150/90 mmHg
D) 2+ pitting edema in lower extremities
Answer B) Clear lung sounds
Rationale: Furosemide is a loop diuretic that reduces fluid
overload. Clear lung sounds indicate decreased pulmonary
congestion. Weight loss (not gain), reduced edema, and
controlled blood pressure are also signs of effectiveness.
3. A client on digoxin reports nausea, vomiting, and sees
yellow halos around lights. What is the priority action?
A) Administer an antiemetic
B) Hold the digoxin and check serum digoxin level
C) Give the digoxin with food to reduce GI upset
D) Reassure the client this is a normal side effect
Answer B) Hold the digoxin and check serum digoxin level
Rationale: Nausea, vomiting, and visual disturbances
(yellow/green halos) are classic signs of digoxin toxicity. The
medication should be held, and the provider notified immediately.
,4. A client with atrial fibrillation is prescribed warfarin. The
INR is 4.5. What action should the nurse take?
A) Administer the next dose as scheduled
B) Hold the dose and notify the provider
C) Administer vitamin K 10 mg IM
D) Increase the warfarin dose
Answer B) Hold the dose and notify the provider
Rationale: The therapeutic INR range for atrial fibrillation on
warfarin is 2.0–3.0. An INR of 4.5 is above the therapeutic range
and indicates increased bleeding risk. The dose should be held
and the provider notified.
5. A client is receiving IV heparin. The aPTT is 120 seconds,
and the control is 30 seconds. Which action should the nurse
take?
A) Increase the heparin infusion rate
B) Prepare to administer protamine sulfate
C) Continue the infusion and recheck in 4 hours
D) Administer vitamin K
Answer B) Prepare to administer protamine sulfate
Rationale: The therapeutic aPTT range for heparin is 1.5–2.5 times
the control (45–75 seconds). An aPTT of 120 seconds indicates
excessive anticoagulation with high bleeding risk. Protamine
, sulfate is the specific antidote that reverses heparin's effects.
Vitamin K reverses warfarin, not heparin.
6. Which adverse effects should the nurse monitor for in a
client receiving heparin? (Select all that apply)
A) Bleeding gums
B) Bruising
C) Hypertension
D) Thrombocytopenia
E) Hyperkalemia
Answer A, B, D
Rationale: Heparin can cause bleeding (bleeding gums, bruising)
and heparin-induced thrombocytopenia (HIT). It does not typically
cause hypertension or hyperkalemia.
7. A client with hypertension is prescribed lisinopril. Which
finding requires immediate intervention?
A) Dry cough
B) Serum potassium 5.8 mEq/L
C) Dizziness when standing
D) Angioedema of the lips and tongue
Answer D) Angioedema of the lips and tongue
