ATI PN Adult Med-Surg 2023
Proctored Exam Complete Question
Bank & Clinical Judgment Practice
Plus Verified Answers And
Rationales /GRADED A+
Section 1: Cardiovascular Disorders
1. A client is admitted with a diagnosis of heart failure. Which
clinical manifestation is the nurse most likely to assess?
• A) Weight loss
• B) Jugular vein distention
• C) Bradycardia
• D) Decreased blood pressure
Answer: B) Jugular vein distention
Rationale: Jugular vein distention (JVD) is a classic sign of right-sided
heart failure, indicating fluid volume overload and increased central
venous pressure. Weight loss, bradycardia, and decreased blood
pressure are not primary signs of heart failure.
2. The nurse is caring for a client 24 hours post-cardiac
catheterization. Which finding requires immediate intervention?
• A) Small amount of serous drainage at the insertion site
• B) The client reports pain at the insertion site, rated as a 4 on a 0-
10 scale
• C) The client's foot on the affected side is pale, cold, and pulseless
• D) The client is on bed rest and requests a bedpan
Answer: C) The client's foot on the affected side is pale, cold, and
pulseless
,Rationale: A pale, cold, and pulseless extremity distal to the
catheterization site indicates arterial occlusion, a medical emergency.
Serous drainage and mild pain are expected. Bed rest orders are
standard post-procedure.
3. A client with angina pectoris is prescribed nitroglycerin
sublingually. Which instruction should the nurse include in the
teaching?
• A) "Chew the tablet thoroughly before swallowing."
• B) "Call 911 if the pain is not relieved after taking one tablet."
• C) "Take the medication with a full glass of water."
• D) "You should feel a burning or fizzing sensation immediately."
Answer: B) "Call 911 if the pain is not relieved after taking one
tablet."
Rationale: If chest pain is not relieved after one sublingual nitroglycerin
tablet, the client should call 911 immediately and then may take up to
two more tablets at 5-minute intervals while waiting. The tablet should
be placed under the tongue and allowed to dissolve.
4. A client with hypertension is prescribed an ACE inhibitor. Which
adverse effect should the nurse monitor for?
• A) Hyperkalemia
• B) Hypokalemia
• C) Hypernatremia
• D) Hypocalcemia
Answer: A) Hyperkalemia
Rationale: ACE inhibitors can cause hyperkalemia by reducing
aldosterone secretion, which decreases potassium excretion. Potassium
levels should be monitored.
5. A client with heart failure has a prescription for furosemide.
Which laboratory value should the nurse monitor most closely?
• A) Sodium
• B) Potassium
• C) Chloride
, • D) Calcium
Answer: B) Potassium
Rationale: Furosemide is a loop diuretic that causes potassium wasting.
Hypokalemia can precipitate cardiac dysrhythmias, especially in clients
taking digoxin. Potassium levels should be monitored closely.
6. A client with atrial fibrillation is at highest risk for which
complication?
• A) Heart failure
• B) Myocardial infarction
• C) Stroke
• D) Cardiac tamponade
Answer: C) Stroke
Rationale: Atrial fibrillation increases the risk of stroke due to stasis of
blood in the atria, which can lead to thrombus formation and
embolization to the brain.
7. A nurse is assessing a client with heart failure who reports sudden
onset of dyspnea and is coughing up pink, frothy sputum. Which
action should the nurse take first?
• A) Place the client in high-Fowler's position
• B) Administer furosemide IV push
• C) Apply oxygen via non-rebreather mask
• D) Notify the healthcare provider immediately
Answer: A) Place the client in high-Fowler's position
Rationale: The client is experiencing acute pulmonary edema. The
priority intervention is to position the client upright (high-Fowler's) to
reduce venous return (preload) and facilitate breathing. Oxygen and
furosemide are then given, but positioning is the immediate first step.
8. A client taking digoxin presents with nausea, vomiting, visual
halos (yellow-green halos around lights), and a serum digoxin level
of 2.5 ng/mL. What is the priority nursing intervention?
• A) Administer activated charcoal
, • B) Hold the digoxin and obtain an ECG
• C) Increase the digoxin dose
• D) Encourage a high-potassium diet
Answer: B) Hold the digoxin and obtain an ECG
Rationale: Nausea, vomiting, and visual disturbances are classic signs of
digoxin toxicity. The therapeutic range is 0.5–2 ng/mL; 2.5 ng/mL is toxic.
The priority is to hold the medication and obtain an ECG to assess for
life-threatening dysrhythmias.
9. A nurse is providing discharge teaching to a client with heart
failure. Which statement indicates the client understands the
teaching?
• A) "I will weigh myself weekly."
• B) "I will notify my provider if I gain 2 lbs in 1 day."
• C) "I can stop my medications when I feel better."
• D) "I should increase my fluid intake to 3 L/day."
Answer: B) "I will notify my provider if I gain 2 lbs in 1 day."
Rationale: Daily weight monitoring is essential. A weight gain of 2-3 lbs
in 1 day or 5 lbs in 1 week indicates fluid retention and should be
reported to the provider.
10. A client with infective endocarditis is being assessed. Which
finding suggests cerebral embolization?
• A) Splinter hemorrhages
• B) Osler nodes
• C) Janeway lesions
• D) New-onset left-sided weakness
Answer: D) New-onset left-sided weakness
Rationale: Acute neurological deficit (weakness) in a client with
endocarditis suggests cerebral embolization. Splinter hemorrhages, Osler
nodes, and Janeway lesions are peripheral signs of endocarditis but do
not indicate acute embolization.
11. A nurse is caring for a client with peripheral arterial disease
(PAD). Which finding should the nurse expect?
Proctored Exam Complete Question
Bank & Clinical Judgment Practice
Plus Verified Answers And
Rationales /GRADED A+
Section 1: Cardiovascular Disorders
1. A client is admitted with a diagnosis of heart failure. Which
clinical manifestation is the nurse most likely to assess?
• A) Weight loss
• B) Jugular vein distention
• C) Bradycardia
• D) Decreased blood pressure
Answer: B) Jugular vein distention
Rationale: Jugular vein distention (JVD) is a classic sign of right-sided
heart failure, indicating fluid volume overload and increased central
venous pressure. Weight loss, bradycardia, and decreased blood
pressure are not primary signs of heart failure.
2. The nurse is caring for a client 24 hours post-cardiac
catheterization. Which finding requires immediate intervention?
• A) Small amount of serous drainage at the insertion site
• B) The client reports pain at the insertion site, rated as a 4 on a 0-
10 scale
• C) The client's foot on the affected side is pale, cold, and pulseless
• D) The client is on bed rest and requests a bedpan
Answer: C) The client's foot on the affected side is pale, cold, and
pulseless
,Rationale: A pale, cold, and pulseless extremity distal to the
catheterization site indicates arterial occlusion, a medical emergency.
Serous drainage and mild pain are expected. Bed rest orders are
standard post-procedure.
3. A client with angina pectoris is prescribed nitroglycerin
sublingually. Which instruction should the nurse include in the
teaching?
• A) "Chew the tablet thoroughly before swallowing."
• B) "Call 911 if the pain is not relieved after taking one tablet."
• C) "Take the medication with a full glass of water."
• D) "You should feel a burning or fizzing sensation immediately."
Answer: B) "Call 911 if the pain is not relieved after taking one
tablet."
Rationale: If chest pain is not relieved after one sublingual nitroglycerin
tablet, the client should call 911 immediately and then may take up to
two more tablets at 5-minute intervals while waiting. The tablet should
be placed under the tongue and allowed to dissolve.
4. A client with hypertension is prescribed an ACE inhibitor. Which
adverse effect should the nurse monitor for?
• A) Hyperkalemia
• B) Hypokalemia
• C) Hypernatremia
• D) Hypocalcemia
Answer: A) Hyperkalemia
Rationale: ACE inhibitors can cause hyperkalemia by reducing
aldosterone secretion, which decreases potassium excretion. Potassium
levels should be monitored.
5. A client with heart failure has a prescription for furosemide.
Which laboratory value should the nurse monitor most closely?
• A) Sodium
• B) Potassium
• C) Chloride
, • D) Calcium
Answer: B) Potassium
Rationale: Furosemide is a loop diuretic that causes potassium wasting.
Hypokalemia can precipitate cardiac dysrhythmias, especially in clients
taking digoxin. Potassium levels should be monitored closely.
6. A client with atrial fibrillation is at highest risk for which
complication?
• A) Heart failure
• B) Myocardial infarction
• C) Stroke
• D) Cardiac tamponade
Answer: C) Stroke
Rationale: Atrial fibrillation increases the risk of stroke due to stasis of
blood in the atria, which can lead to thrombus formation and
embolization to the brain.
7. A nurse is assessing a client with heart failure who reports sudden
onset of dyspnea and is coughing up pink, frothy sputum. Which
action should the nurse take first?
• A) Place the client in high-Fowler's position
• B) Administer furosemide IV push
• C) Apply oxygen via non-rebreather mask
• D) Notify the healthcare provider immediately
Answer: A) Place the client in high-Fowler's position
Rationale: The client is experiencing acute pulmonary edema. The
priority intervention is to position the client upright (high-Fowler's) to
reduce venous return (preload) and facilitate breathing. Oxygen and
furosemide are then given, but positioning is the immediate first step.
8. A client taking digoxin presents with nausea, vomiting, visual
halos (yellow-green halos around lights), and a serum digoxin level
of 2.5 ng/mL. What is the priority nursing intervention?
• A) Administer activated charcoal
, • B) Hold the digoxin and obtain an ECG
• C) Increase the digoxin dose
• D) Encourage a high-potassium diet
Answer: B) Hold the digoxin and obtain an ECG
Rationale: Nausea, vomiting, and visual disturbances are classic signs of
digoxin toxicity. The therapeutic range is 0.5–2 ng/mL; 2.5 ng/mL is toxic.
The priority is to hold the medication and obtain an ECG to assess for
life-threatening dysrhythmias.
9. A nurse is providing discharge teaching to a client with heart
failure. Which statement indicates the client understands the
teaching?
• A) "I will weigh myself weekly."
• B) "I will notify my provider if I gain 2 lbs in 1 day."
• C) "I can stop my medications when I feel better."
• D) "I should increase my fluid intake to 3 L/day."
Answer: B) "I will notify my provider if I gain 2 lbs in 1 day."
Rationale: Daily weight monitoring is essential. A weight gain of 2-3 lbs
in 1 day or 5 lbs in 1 week indicates fluid retention and should be
reported to the provider.
10. A client with infective endocarditis is being assessed. Which
finding suggests cerebral embolization?
• A) Splinter hemorrhages
• B) Osler nodes
• C) Janeway lesions
• D) New-onset left-sided weakness
Answer: D) New-onset left-sided weakness
Rationale: Acute neurological deficit (weakness) in a client with
endocarditis suggests cerebral embolization. Splinter hemorrhages, Osler
nodes, and Janeway lesions are peripheral signs of endocarditis but do
not indicate acute embolization.
11. A nurse is caring for a client with peripheral arterial disease
(PAD). Which finding should the nurse expect?
