ATI Adult Medical Surgical Nursing (CMS)
Exam Actual Questions and Answers With Expert
Explanation (2026/2027 Update) | Complete A+ Guide
1. A nurse is assessing a client with left-sided heart failure.
Which finding is most expected?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in lung bases
D. Hepatomegaly
Answer: C. Crackles in lung bases
Rationale: Left-sided heart failure causes fluid backup into the lungs (pulmonary
congestion), leading to crackles. JVD, peripheral edema, and hepatomegaly are signs of right-
sided failure.
2. A client post-MI develops chest pain unrelieved by nitroglycerin. The nurse should
first:
A. Administer morphine sulfate
B. Repeat nitroglycerin
C. Obtain an ECG
D. Assess blood pressure
Answer: D. Assess blood pressure
Rationale: Before administering further nitroglycerin or morphine, assess BP to prevent
hypotension. After assessment, notify provider and obtain ECG.
3. A nurse is teaching a client with hypertension about dietary changes. Which
statement indicates understanding?
A. “I can use salt substitutes freely.”
B. “I should limit potassium-rich foods.”
,C. “I will read labels for sodium content.”
D. “I need to avoid all fats.”
Answer: C. “I will read labels for sodium content.”
Rationale: Sodium restriction is key. Salt substitutes contain potassium, which may be
harmful if on ACE inhibitors/ARBs (risk of hyperkalemia). Healthy fats are allowed.
4. A client with atrial fibrillation is prescribed warfarin. The nurse should monitor:
A. aPTT
B. INR
C. Platelet count
D. Bleeding time
Answer: B. INR
Rationale: Warfarin therapy is monitored with INR (therapeutic range 2–3 for atrial
fibrillation). aPTT monitors heparin.
5. A nurse is caring for a client who has deep vein thrombosis (DVT). Which action
should the nurse take first?
A. Massage the affected leg
B. Apply sequential compression devices
C. Administer the prescribed anticoagulant
D. Encourage vigorous ambulation
Answer: C. Administer the prescribed anticoagulant
Rationale: Anticoagulants help prevent clot extension and pulmonary embolism. Massaging
the leg can dislodge the clot, and compression devices are contraindicated in active DVT.
6. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. Which finding indicates oxygen therapy is effective?
A. Respiratory rate of 30/min
B. Oxygen saturation of 92%
,C. Increased accessory muscle use
D. Cyanosis of the lips
Answer: B. Oxygen saturation of 92%
Rationale: For many clients with COPD, maintaining oxygen saturation between 88% and
92% is an appropriate goal that improves oxygenation while minimizing the risk of
suppressing respiratory drive.
7. A nurse is assessing a client with a pneumothorax. Which finding requires immediate
intervention?
A. Tracheal deviation
B. Mild chest discomfort
C. Nonproductive cough
D. Respiratory rate of 22/min
Answer: A. Tracheal deviation
Rationale: Tracheal deviation may indicate a tension pneumothorax, a life-threatening
emergency requiring immediate decompression.
8. A client is admitted with acute pancreatitis. Which laboratory value should the nurse
expect to be elevated?
A. Troponin
B. Lipase
C. Hemoglobin
D. Albumin
Answer: B. Lipase
Rationale: Lipase is the most specific laboratory marker for acute pancreatitis and typically
remains elevated longer than amylase.
9. A nurse is caring for a client receiving furosemide. Which laboratory value requires
immediate follow-up?
, A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.2 mg/dL
D. Glucose 98 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause hypokalemia, increasing the risk for dysrhythmias and
muscle weakness.
10. A client with diabetes mellitus reports shaking and sweating. What is the nurse's
priority action?
A. Administer insulin
B. Check the client's blood glucose level
C. Encourage exercise
D. Restrict oral fluids
Answer: B. Check the client's blood glucose level
Rationale: Shaking and sweating are signs of hypoglycemia. Blood glucose should be
assessed immediately to guide treatment.
11. A nurse is assessing a client with hyperthyroidism. Which finding is expected?
A. Bradycardia
B. Weight gain
C. Heat intolerance
D. Constipation
Answer: C. Heat intolerance
Rationale: Hyperthyroidism increases metabolism, causing heat intolerance, tachycardia,
weight loss, and nervousness.
Exam Actual Questions and Answers With Expert
Explanation (2026/2027 Update) | Complete A+ Guide
1. A nurse is assessing a client with left-sided heart failure.
Which finding is most expected?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in lung bases
D. Hepatomegaly
Answer: C. Crackles in lung bases
Rationale: Left-sided heart failure causes fluid backup into the lungs (pulmonary
congestion), leading to crackles. JVD, peripheral edema, and hepatomegaly are signs of right-
sided failure.
2. A client post-MI develops chest pain unrelieved by nitroglycerin. The nurse should
first:
A. Administer morphine sulfate
B. Repeat nitroglycerin
C. Obtain an ECG
D. Assess blood pressure
Answer: D. Assess blood pressure
Rationale: Before administering further nitroglycerin or morphine, assess BP to prevent
hypotension. After assessment, notify provider and obtain ECG.
3. A nurse is teaching a client with hypertension about dietary changes. Which
statement indicates understanding?
A. “I can use salt substitutes freely.”
B. “I should limit potassium-rich foods.”
,C. “I will read labels for sodium content.”
D. “I need to avoid all fats.”
Answer: C. “I will read labels for sodium content.”
Rationale: Sodium restriction is key. Salt substitutes contain potassium, which may be
harmful if on ACE inhibitors/ARBs (risk of hyperkalemia). Healthy fats are allowed.
4. A client with atrial fibrillation is prescribed warfarin. The nurse should monitor:
A. aPTT
B. INR
C. Platelet count
D. Bleeding time
Answer: B. INR
Rationale: Warfarin therapy is monitored with INR (therapeutic range 2–3 for atrial
fibrillation). aPTT monitors heparin.
5. A nurse is caring for a client who has deep vein thrombosis (DVT). Which action
should the nurse take first?
A. Massage the affected leg
B. Apply sequential compression devices
C. Administer the prescribed anticoagulant
D. Encourage vigorous ambulation
Answer: C. Administer the prescribed anticoagulant
Rationale: Anticoagulants help prevent clot extension and pulmonary embolism. Massaging
the leg can dislodge the clot, and compression devices are contraindicated in active DVT.
6. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. Which finding indicates oxygen therapy is effective?
A. Respiratory rate of 30/min
B. Oxygen saturation of 92%
,C. Increased accessory muscle use
D. Cyanosis of the lips
Answer: B. Oxygen saturation of 92%
Rationale: For many clients with COPD, maintaining oxygen saturation between 88% and
92% is an appropriate goal that improves oxygenation while minimizing the risk of
suppressing respiratory drive.
7. A nurse is assessing a client with a pneumothorax. Which finding requires immediate
intervention?
A. Tracheal deviation
B. Mild chest discomfort
C. Nonproductive cough
D. Respiratory rate of 22/min
Answer: A. Tracheal deviation
Rationale: Tracheal deviation may indicate a tension pneumothorax, a life-threatening
emergency requiring immediate decompression.
8. A client is admitted with acute pancreatitis. Which laboratory value should the nurse
expect to be elevated?
A. Troponin
B. Lipase
C. Hemoglobin
D. Albumin
Answer: B. Lipase
Rationale: Lipase is the most specific laboratory marker for acute pancreatitis and typically
remains elevated longer than amylase.
9. A nurse is caring for a client receiving furosemide. Which laboratory value requires
immediate follow-up?
, A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Calcium 9.2 mg/dL
D. Glucose 98 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Furosemide can cause hypokalemia, increasing the risk for dysrhythmias and
muscle weakness.
10. A client with diabetes mellitus reports shaking and sweating. What is the nurse's
priority action?
A. Administer insulin
B. Check the client's blood glucose level
C. Encourage exercise
D. Restrict oral fluids
Answer: B. Check the client's blood glucose level
Rationale: Shaking and sweating are signs of hypoglycemia. Blood glucose should be
assessed immediately to guide treatment.
11. A nurse is assessing a client with hyperthyroidism. Which finding is expected?
A. Bradycardia
B. Weight gain
C. Heat intolerance
D. Constipation
Answer: C. Heat intolerance
Rationale: Hyperthyroidism increases metabolism, causing heat intolerance, tachycardia,
weight loss, and nervousness.
