ATI Adult Medical-Surgical CMS Exam
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has acute pulmonary edema
related to heart failure. Which finding requires the nurse's
priority intervention?
A. 2+ bilateral ankle edema
B. Blood pressure of 154/88 mm Hg
C. Pink, frothy sputum and severe dyspnea
D. Weight gain of 1 kg over 3 days
Correct answer: C. Pink, frothy sputum and severe dyspnea
Rationale: Pink, frothy sputum with severe dyspnea is
characteristic of acute pulmonary edema, which indicates fluid
accumulation in the alveoli and impaired gas exchange. The
immediate nursing priority is to support oxygenation and
breathing, typically by positioning the client upright,
administering oxygen as prescribed, and rapidly implementing
ordered therapies such as diuretics. Peripheral edema,
,hypertension, and gradual weight gain are important
manifestations of fluid retention but are less immediately life-
threatening than acute respiratory compromise.
Question 2
A client with heart failure is prescribed furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Platelet count
D. Hemoglobin
Correct answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of sodium and water and can also cause significant
potassium loss. Hypokalemia can produce muscle weakness,
dysrhythmias, and potentially life-threatening cardiac
complications. The nurse should monitor serum potassium and
assess for manifestations such as weakness, muscle cramps, and
abnormal cardiac rhythms. Calcium, platelets, and hemoglobin
are not the primary laboratory concerns associated with routine
furosemide therapy.
Question 3
,A client reports crushing substernal chest pain radiating to the
left arm and jaw. The ECG demonstrates ST-segment elevation.
Which action should the nurse take first?
A. Obtain a fasting lipid panel
B. Administer prescribed oxygen if hypoxemia is present
C. Encourage the client to ambulate
D. Schedule an outpatient stress test
Correct answer: B. Administer prescribed oxygen if hypoxemia
is present
Rationale: ST-segment elevation can indicate acute myocardial
injury requiring immediate evaluation and treatment. The nurse
should rapidly assess airway, breathing, circulation, oxygen
saturation, and hemodynamic stability while activating the
appropriate acute coronary syndrome response. Oxygen is
indicated when the client is hypoxemic or otherwise has
impaired oxygenation; routine oxygen administration to every
client with chest pain is not necessary. A lipid panel and stress
test are not priorities during an acute presentation, and
ambulation is inappropriate.
Question 4
, A nurse is caring for a client receiving warfarin therapy. Which
laboratory test is used to evaluate the therapeutic effect of this
medication?
A. aPTT
B. INR
C. Troponin
D. Serum sodium
Correct answer: B. INR
Rationale: Warfarin therapy is monitored primarily with the
international normalized ratio (INR), which standardizes the
prothrombin time and evaluates the medication's anticoagulant
effect. The nurse should monitor the INR according to the
prescribed treatment range and assess for bleeding. The aPTT is
generally used to monitor unfractionated heparin therapy.
Troponin evaluates myocardial injury, while sodium reflects fluid
and electrolyte status rather than anticoagulation.
Question 5
A client receiving a blood transfusion develops chills, fever, and
low back pain 15 minutes after the transfusion begins. What
should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has acute pulmonary edema
related to heart failure. Which finding requires the nurse's
priority intervention?
A. 2+ bilateral ankle edema
B. Blood pressure of 154/88 mm Hg
C. Pink, frothy sputum and severe dyspnea
D. Weight gain of 1 kg over 3 days
Correct answer: C. Pink, frothy sputum and severe dyspnea
Rationale: Pink, frothy sputum with severe dyspnea is
characteristic of acute pulmonary edema, which indicates fluid
accumulation in the alveoli and impaired gas exchange. The
immediate nursing priority is to support oxygenation and
breathing, typically by positioning the client upright,
administering oxygen as prescribed, and rapidly implementing
ordered therapies such as diuretics. Peripheral edema,
,hypertension, and gradual weight gain are important
manifestations of fluid retention but are less immediately life-
threatening than acute respiratory compromise.
Question 2
A client with heart failure is prescribed furosemide. Which
laboratory value is most important for the nurse to monitor?
A. Calcium
B. Potassium
C. Platelet count
D. Hemoglobin
Correct answer: B. Potassium
Rationale: Furosemide is a loop diuretic that increases urinary
excretion of sodium and water and can also cause significant
potassium loss. Hypokalemia can produce muscle weakness,
dysrhythmias, and potentially life-threatening cardiac
complications. The nurse should monitor serum potassium and
assess for manifestations such as weakness, muscle cramps, and
abnormal cardiac rhythms. Calcium, platelets, and hemoglobin
are not the primary laboratory concerns associated with routine
furosemide therapy.
Question 3
,A client reports crushing substernal chest pain radiating to the
left arm and jaw. The ECG demonstrates ST-segment elevation.
Which action should the nurse take first?
A. Obtain a fasting lipid panel
B. Administer prescribed oxygen if hypoxemia is present
C. Encourage the client to ambulate
D. Schedule an outpatient stress test
Correct answer: B. Administer prescribed oxygen if hypoxemia
is present
Rationale: ST-segment elevation can indicate acute myocardial
injury requiring immediate evaluation and treatment. The nurse
should rapidly assess airway, breathing, circulation, oxygen
saturation, and hemodynamic stability while activating the
appropriate acute coronary syndrome response. Oxygen is
indicated when the client is hypoxemic or otherwise has
impaired oxygenation; routine oxygen administration to every
client with chest pain is not necessary. A lipid panel and stress
test are not priorities during an acute presentation, and
ambulation is inappropriate.
Question 4
, A nurse is caring for a client receiving warfarin therapy. Which
laboratory test is used to evaluate the therapeutic effect of this
medication?
A. aPTT
B. INR
C. Troponin
D. Serum sodium
Correct answer: B. INR
Rationale: Warfarin therapy is monitored primarily with the
international normalized ratio (INR), which standardizes the
prothrombin time and evaluates the medication's anticoagulant
effect. The nurse should monitor the INR according to the
prescribed treatment range and assess for bleeding. The aPTT is
generally used to monitor unfractionated heparin therapy.
Troponin evaluates myocardial injury, while sodium reflects fluid
and electrolyte status rather than anticoagulation.
Question 5
A client receiving a blood transfusion develops chills, fever, and
low back pain 15 minutes after the transfusion begins. What
should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
