ATI Capstone Adult Medical Surgical
Assessment 2 with questions with
correct answers and rationale
updated 2026
Cardiovascular System (Questions 1–10)
Question 1
A nurse is assessing a client who is 4 hours postoperative following a coronary artery bypass graft
(CABG). The nurse notes that the client's chest tube drainage has suddenly decreased from 150
mL/hr to 10 mL/hr, and the client’s blood pressure has dropped from 120/80 mmHg to 92/56 mmHg.
Which of the following complications should the nurse suspect?
A. Pulmonary embolism
B. Tension pneumothorax
C. Cardiac tamponade
D. Hypovolemic shock
Rationale: A sudden decrease in chest tube drainage along with hypotension is a classic sign of
cardiac tamponade, caused by accumulation of blood in the pericardial sac compressing the heart.
This prevents adequate diastolic filling, leading to decreased cardiac output, hypotension, jugular
venous distention (JVD), and muffled heart sounds (Beck's triad). While hypovolemic shock features
hypotension, the sudden drop in chest tube drainage suggests an obstruction leading to
accumulation/compression rather than simple volume loss.
Question 2
A nurse is caring for a client with history of heart failure who presents with dyspnea, pink frothy
sputum, and crackles throughout both lung fields. Which of the following medications should the
nurse prepare to administer first?
A. Furosemide IV push
B. Metoprolol IV push
C. Enalapril PO
D. Digoxin IV push
,Rationale: The client is exhibiting signs of acute pulmonary edema, a life-threatening complication of
heart failure. Rapid diuresis via IV loop diuretics (furosemide) is the priority intervention to reduce
preload, clear fluid from the alveoli, and improve oxygenation. Beta-blockers (metoprolol) are
contraindicated in acute decompensated heart failure due to their negative inotropic effects.
Question 3
A nurse is reviewing the electrocardiogram (ECG) of a client and notes a progress lengthening of the
PR interval until a QRS complex is dropped. The nurse should identify this rhythm as which of the
following?
A. First-degree AV block
B. Second-degree AV block, Mobitz Type I (Wenckebach)
C. Second-degree AV block, Mobitz Type II
D. Third-degree AV block
Rationale: Second-degree AV block, Mobitz Type I (Wenckebach) is characterized by progressive
prolongation of the PR interval in consecutive cycles until a QRS complex is dropped ("longer, longer,
longer, drop, now you have a Wenckebach"). First-degree block has a prolonged but constant PR
interval. Mobitz Type II has constant PR intervals with intermittent dropped QRS complexes. Third-
degree block has completely dissociated P waves and QRS complexes.
Question 4
A nurse is caring for a client who is taking warfarin for chronic atrial fibrillation. The client's morning
lab results reveal an INR of 5.2. The nurse notes no active bleeding. Which of the following actions
should the nurse anticipate taking?
A. Administer protamine sulfate.
B. Hold the next dose of warfarin and prepare to administer Vitamin K.
C. Prepare the client for an emergency blood transfusion.
D. Increase the daily dose of warfarin.
Rationale: For an INR between 5.0 and 9.0 without active bleeding, the standard practice is to hold
one or more doses of warfarin, monitor the INR closely, and administer oral or parenteral Vitamin K
(phytonadione) to reverse the coagulation defect if indicated. Protamine sulfate is the reversal agent
for heparin, not warfarin.
Question 5
A nurse is providing discharge teaching to a client who has a new prescription for sublingual
nitroglycerin tablets for stable angina. Which of the following instructions should the nurse include?
A. "Store the medication bottle on your windowsill so it is easy to find."
B. "Take up to 5 tablets, 10 minutes apart, if chest pain continues."
,C. "Place one tablet under your tongue at the onset of chest pain and call 911 if pain is not relieved
after 5 minutes."
D. "Swallow the tablet with a full glass of water."
Rationale: Sublingual nitroglycerin must dissolve under the tongue to bypass first-pass hepatic
metabolism. If chest pain does not improve or worsens 5 minutes after taking the first dose, the
client must call 911 immediately before taking a second dose (a maximum of 3 doses, 5 minutes
apart, can be taken while awaiting emergency services). Nitroglycerin must be kept in its original
dark glass bottle away from light and heat.
Question 6
A nurse is monitoring a client who has a temporary transvenous pacemaker. The nurse notes
pacemaker spikes on the ECG monitor that are not followed by a QRS complex. The nurse should
document this finding as which of the following pacemaker malfunctions?
A. Failure to sense
B. Failure to pace
C. Failure to capture
D. Oversensing
Rationale: Failure to capture occurs when the pacemaker fires an electrical impulse (visible as a
pacemaker spike) but the myocardium fails to depolarize in response (no QRS complex follows the
spike). Failure to pace is characterized by a complete absence of pacemaker spikes when they should
have fired. Failure to sense occurs when the pacemaker fails to recognize intrinsic cardiac activity
and fires randomly.
Question 7
A nurse is assessing a client with peripheral arterial disease (PAD). Which of the following clinical
findings should the nurse expect to observe?
A. Edema around the ankles
B. Bronze-brown pigmentation of the skin
C. Pain in the calves when walking that is relieved by rest
D. Warm, moist skin on the lower extremities
Rationale: Pain in the calves when walking that is relieved by rest is known as intermittent
claudication, a hallmark sign of peripheral arterial disease (PAD) caused by arterial insufficiency and
ischemia during exercise. Edema, brownish pigmentation, and warm/moist skin are characteristic
findings of chronic venous insufficiency rather than arterial disease.
Question 8
, A nurse is preparing to administer digoxin to a client with heart failure. Which of the following
clinical findings should prompt the nurse to hold the medication and notify the healthcare provider?
A. Blood pressure of 140/90 mmHg
B. Serum potassium level of 3.1 mEq/L
C. Heart rate of 82 beats per minute
D. Digoxin level of 0.8 ng/mL
Rationale: Hypokalemia (serum potassium level < 3.5 mEq/L) sensitizes the myocardium to digoxin,
greatly increasing the risk of digoxin toxicity. Therefore, if the potassium level is low, the nurse
should hold the dose and notify the provider. A heart rate of 82 bpm and a digoxin level of 0.8 ng/mL
(normal therapeutic range: 0.5–2.0 ng/mL) are within safe limits.
Question 9
A nurse is evaluating a client with suspected deep vein thrombosis (DVT). Which of the following
diagnostic tests is considered the gold standard for confirming this diagnosis non-invasively?
A. Electrocardiogram (ECG)
B. Duplex venous ultrasonography
C. Serum D-dimer assay
D. Chest X-ray
Rationale: Duplex venous ultrasonography is the primary, non-invasive diagnostic test used to
visualize the veins and confirm the presence of a deep vein thrombosis (DVT). While a D-dimer test
can rule out a clot if negative, a positive D-dimer is non-specific and requires ultrasound
confirmation.
Question 10
A nurse is caring for a client with infective endocarditis. Which of the following assessment findings
represents a potential systemic embolization complication?
A. Sudden onset of left-sided weakness and slurred speech
B. Pleuritic chest pain and dyspnea
C. Splinter hemorrhages in the nail beds
D. Bilateral lower extremity edema
Rationale: Left-sided weakness and slurred speech indicate an acute stroke, which is a major
complication of infective endocarditis caused by vegetative emboli breaking off the left side of the
heart and traveling to the cerebral circulation. Pleuritic chest pain/dyspnea suggests pulmonary
Assessment 2 with questions with
correct answers and rationale
updated 2026
Cardiovascular System (Questions 1–10)
Question 1
A nurse is assessing a client who is 4 hours postoperative following a coronary artery bypass graft
(CABG). The nurse notes that the client's chest tube drainage has suddenly decreased from 150
mL/hr to 10 mL/hr, and the client’s blood pressure has dropped from 120/80 mmHg to 92/56 mmHg.
Which of the following complications should the nurse suspect?
A. Pulmonary embolism
B. Tension pneumothorax
C. Cardiac tamponade
D. Hypovolemic shock
Rationale: A sudden decrease in chest tube drainage along with hypotension is a classic sign of
cardiac tamponade, caused by accumulation of blood in the pericardial sac compressing the heart.
This prevents adequate diastolic filling, leading to decreased cardiac output, hypotension, jugular
venous distention (JVD), and muffled heart sounds (Beck's triad). While hypovolemic shock features
hypotension, the sudden drop in chest tube drainage suggests an obstruction leading to
accumulation/compression rather than simple volume loss.
Question 2
A nurse is caring for a client with history of heart failure who presents with dyspnea, pink frothy
sputum, and crackles throughout both lung fields. Which of the following medications should the
nurse prepare to administer first?
A. Furosemide IV push
B. Metoprolol IV push
C. Enalapril PO
D. Digoxin IV push
,Rationale: The client is exhibiting signs of acute pulmonary edema, a life-threatening complication of
heart failure. Rapid diuresis via IV loop diuretics (furosemide) is the priority intervention to reduce
preload, clear fluid from the alveoli, and improve oxygenation. Beta-blockers (metoprolol) are
contraindicated in acute decompensated heart failure due to their negative inotropic effects.
Question 3
A nurse is reviewing the electrocardiogram (ECG) of a client and notes a progress lengthening of the
PR interval until a QRS complex is dropped. The nurse should identify this rhythm as which of the
following?
A. First-degree AV block
B. Second-degree AV block, Mobitz Type I (Wenckebach)
C. Second-degree AV block, Mobitz Type II
D. Third-degree AV block
Rationale: Second-degree AV block, Mobitz Type I (Wenckebach) is characterized by progressive
prolongation of the PR interval in consecutive cycles until a QRS complex is dropped ("longer, longer,
longer, drop, now you have a Wenckebach"). First-degree block has a prolonged but constant PR
interval. Mobitz Type II has constant PR intervals with intermittent dropped QRS complexes. Third-
degree block has completely dissociated P waves and QRS complexes.
Question 4
A nurse is caring for a client who is taking warfarin for chronic atrial fibrillation. The client's morning
lab results reveal an INR of 5.2. The nurse notes no active bleeding. Which of the following actions
should the nurse anticipate taking?
A. Administer protamine sulfate.
B. Hold the next dose of warfarin and prepare to administer Vitamin K.
C. Prepare the client for an emergency blood transfusion.
D. Increase the daily dose of warfarin.
Rationale: For an INR between 5.0 and 9.0 without active bleeding, the standard practice is to hold
one or more doses of warfarin, monitor the INR closely, and administer oral or parenteral Vitamin K
(phytonadione) to reverse the coagulation defect if indicated. Protamine sulfate is the reversal agent
for heparin, not warfarin.
Question 5
A nurse is providing discharge teaching to a client who has a new prescription for sublingual
nitroglycerin tablets for stable angina. Which of the following instructions should the nurse include?
A. "Store the medication bottle on your windowsill so it is easy to find."
B. "Take up to 5 tablets, 10 minutes apart, if chest pain continues."
,C. "Place one tablet under your tongue at the onset of chest pain and call 911 if pain is not relieved
after 5 minutes."
D. "Swallow the tablet with a full glass of water."
Rationale: Sublingual nitroglycerin must dissolve under the tongue to bypass first-pass hepatic
metabolism. If chest pain does not improve or worsens 5 minutes after taking the first dose, the
client must call 911 immediately before taking a second dose (a maximum of 3 doses, 5 minutes
apart, can be taken while awaiting emergency services). Nitroglycerin must be kept in its original
dark glass bottle away from light and heat.
Question 6
A nurse is monitoring a client who has a temporary transvenous pacemaker. The nurse notes
pacemaker spikes on the ECG monitor that are not followed by a QRS complex. The nurse should
document this finding as which of the following pacemaker malfunctions?
A. Failure to sense
B. Failure to pace
C. Failure to capture
D. Oversensing
Rationale: Failure to capture occurs when the pacemaker fires an electrical impulse (visible as a
pacemaker spike) but the myocardium fails to depolarize in response (no QRS complex follows the
spike). Failure to pace is characterized by a complete absence of pacemaker spikes when they should
have fired. Failure to sense occurs when the pacemaker fails to recognize intrinsic cardiac activity
and fires randomly.
Question 7
A nurse is assessing a client with peripheral arterial disease (PAD). Which of the following clinical
findings should the nurse expect to observe?
A. Edema around the ankles
B. Bronze-brown pigmentation of the skin
C. Pain in the calves when walking that is relieved by rest
D. Warm, moist skin on the lower extremities
Rationale: Pain in the calves when walking that is relieved by rest is known as intermittent
claudication, a hallmark sign of peripheral arterial disease (PAD) caused by arterial insufficiency and
ischemia during exercise. Edema, brownish pigmentation, and warm/moist skin are characteristic
findings of chronic venous insufficiency rather than arterial disease.
Question 8
, A nurse is preparing to administer digoxin to a client with heart failure. Which of the following
clinical findings should prompt the nurse to hold the medication and notify the healthcare provider?
A. Blood pressure of 140/90 mmHg
B. Serum potassium level of 3.1 mEq/L
C. Heart rate of 82 beats per minute
D. Digoxin level of 0.8 ng/mL
Rationale: Hypokalemia (serum potassium level < 3.5 mEq/L) sensitizes the myocardium to digoxin,
greatly increasing the risk of digoxin toxicity. Therefore, if the potassium level is low, the nurse
should hold the dose and notify the provider. A heart rate of 82 bpm and a digoxin level of 0.8 ng/mL
(normal therapeutic range: 0.5–2.0 ng/mL) are within safe limits.
Question 9
A nurse is evaluating a client with suspected deep vein thrombosis (DVT). Which of the following
diagnostic tests is considered the gold standard for confirming this diagnosis non-invasively?
A. Electrocardiogram (ECG)
B. Duplex venous ultrasonography
C. Serum D-dimer assay
D. Chest X-ray
Rationale: Duplex venous ultrasonography is the primary, non-invasive diagnostic test used to
visualize the veins and confirm the presence of a deep vein thrombosis (DVT). While a D-dimer test
can rule out a clot if negative, a positive D-dimer is non-specific and requires ultrasound
confirmation.
Question 10
A nurse is caring for a client with infective endocarditis. Which of the following assessment findings
represents a potential systemic embolization complication?
A. Sudden onset of left-sided weakness and slurred speech
B. Pleuritic chest pain and dyspnea
C. Splinter hemorrhages in the nail beds
D. Bilateral lower extremity edema
Rationale: Left-sided weakness and slurred speech indicate an acute stroke, which is a major
complication of infective endocarditis caused by vegetative emboli breaking off the left side of the
heart and traveling to the cerebral circulation. Pleuritic chest pain/dyspnea suggests pulmonary
