ATI Med Surg Test Bank 2020/2021
Correct Questions and Answers with
Reliable Rationales
SECTION 1: CARDIOVASCULAR DISORDERS (Questions 1–25)
Question 1
A nurse is caring for a client who has left-sided heart failure. Which of the following
manifestations should the nurse expect?
A. Pedal edema
B. Jugular venous distention
C. Daytime oliguria
D. Hepatomegaly
Correct Answer: C. Daytime oliguria
Rationale: Left-sided heart failure causes decreased cardiac output, leading to reduced
renal perfusion and oliguria during the day when the client is upright and active. Pedal edema,
jugular venous distention, and hepatomegaly are manifestations of right-sided heart failure due
to systemic venous congestion .
Question 2
A client with acute anterior-wall ST-elevation myocardial infarction is receiving alteplase (tPA).
Which findings require the nurse to stop the infusion? (Select All That Apply)
A. Sudden severe headache
B. IV site ecchymosis 2 cm
C. Blood pressure 180/100 mmHg
D. Gross blood in Foley catheter
E. Epistaxis lasting 5 minutes
Correct Answer: A, D
, Rationale: Sudden severe headache is a hallmark of intracranial hemorrhage, an absolute
contraindication requiring immediate cessation of thrombolytic therapy. Gross blood in the
Foley catheter indicates genitourinary bleeding, which may be major. IV site ecchymosis is minor
oozing managed with pressure. Hypertension should be treated but does not require stopping
the infusion if no active bleeding occurs. Minor epistaxis can be managed with packing or nasal
spray .
Question 3
The nurse is caring for a client on continuous cardiac monitoring. Which task can be safely
delegated to an unlicensed assistive personnel (UAP)?
A. Document heart rate every hour from the monitor
B. Interpret rhythm changes
C. Obtain a 12-lead ECG
D. Initiate synchronized cardioversion
Correct Answer: A. Document heart rate every hour from the monitor
Rationale: UAPs may collect and document routine data such as heart rate from a monitor.
Interpretation of rhythms, obtaining 12-lead ECGs, and initiating synchronized cardioversion
require licensed nursing judgment and skill .
Question 4
A client with hypertensive crisis (BP 220/130 mmHg) is started on nicardipine 5 mg/hr IV. Two
minutes after initiation, the BP is 218/128 mmHg. What is the nurse's best action?
A. Increase drip to 7.5 mg/hr
B. Notify provider immediately
C. Recheck BP in 5 minutes using the same cuff
D. Place client in Trendelenburg position
Correct Answer: C. Recheck BP in 5 minutes using the same cuff
Rationale: Rapid-acting vasodilators require 5–15 minutes for full effect. The nurse should
recheck per protocol before titrating. Trendelenburg worsens cerebral perfusion and is
contraindicated in hypertensive crisis .
,Question 5
A client is discharged on warfarin 5 mg daily. Which statement indicates correct understanding?
A. "I will take aspirin if I have chest pain."
B. "I should eat a spinach salad every day."
C. "I will check my INR every month."
D. "I will use an electric razor."
Correct Answer: D. "I will use an electric razor."
Rationale: An electric razor prevents bleeding injury. Daily spinach (vitamin K) would
destabilize INR; aspirin increases bleeding risk; INR is checked more frequently initially, then
weekly to monthly once stable .
Question 6
The monitor shows PR 0.28 seconds, regular RR, QRS 0.08 seconds. The nurse interprets this as:
A. First-degree AV block
B. Second-degree AV block Type I
C. Second-degree AV block Type II
D. Third-degree AV block
Correct Answer: A. First-degree AV block
Rationale: A PR interval greater than 0.20 seconds with a regular rhythm and normal QRS
indicates first-degree AV block. The PR interval is prolonged but all impulses are conducted .
Question 7
A nurse is assessing a client who is 4 hours postoperative following a subtotal thyroidectomy.
The client reports tingling in the fingers and around the mouth. Which action should the nurse
take first?
A. Assess the surgical dressing for bleeding
B. Check for Chvostek's sign
C. Administer an oral calcium supplement
D. Request a prescription for an opioid analgesic
Correct Answer: B. Check for Chvostek's sign
, Rationale: Circumoral paresthesia and tingling in the fingers are classic early signs of
hypocalcemia, a potential complication of thyroidectomy if parathyroid glands were damaged.
Checking for Chvostek's sign confirms hypocalcemia. The nurse must verify this clinical cue
before interventions .
Question 8
A nurse in the emergency department is caring for a client who reports crushing chest pain
radiating to the left arm. The 12-lead ECG shows ST-segment elevation in leads V1 through V4.
Which intervention is the absolute priority?
A. Administer morphine sulfate IV
B. Administer oxygen therapy if saturation is below 90%
C. Administer chewable aspirin
D. Obtain blood samples for cardiac enzymes
Correct Answer: C. Administer chewable aspirin
Rationale: In acute MI (STEMI), platelet aggregation must be inhibited immediately to
prevent further occlusion. While oxygen, morphine, and labs are important, administering
chewable aspirin has the most significant immediate impact on reducing mortality .
Question 9
A nurse is assessing a client with a history of left-sided heart failure. Which clinical finding
should the nurse expect?
A. Jugular venous distention
B. Dependent pitting edema
C. Hepatomegaly
D. Oliguria during the day
Correct Answer: D. Oliguria during the day
Rationale: Left-sided heart failure causes decreased cardiac output and reduced renal
perfusion during waking hours, leading to daytime oliguria. Options A, B, and C are signs of
right-sided heart failure .
Correct Questions and Answers with
Reliable Rationales
SECTION 1: CARDIOVASCULAR DISORDERS (Questions 1–25)
Question 1
A nurse is caring for a client who has left-sided heart failure. Which of the following
manifestations should the nurse expect?
A. Pedal edema
B. Jugular venous distention
C. Daytime oliguria
D. Hepatomegaly
Correct Answer: C. Daytime oliguria
Rationale: Left-sided heart failure causes decreased cardiac output, leading to reduced
renal perfusion and oliguria during the day when the client is upright and active. Pedal edema,
jugular venous distention, and hepatomegaly are manifestations of right-sided heart failure due
to systemic venous congestion .
Question 2
A client with acute anterior-wall ST-elevation myocardial infarction is receiving alteplase (tPA).
Which findings require the nurse to stop the infusion? (Select All That Apply)
A. Sudden severe headache
B. IV site ecchymosis 2 cm
C. Blood pressure 180/100 mmHg
D. Gross blood in Foley catheter
E. Epistaxis lasting 5 minutes
Correct Answer: A, D
, Rationale: Sudden severe headache is a hallmark of intracranial hemorrhage, an absolute
contraindication requiring immediate cessation of thrombolytic therapy. Gross blood in the
Foley catheter indicates genitourinary bleeding, which may be major. IV site ecchymosis is minor
oozing managed with pressure. Hypertension should be treated but does not require stopping
the infusion if no active bleeding occurs. Minor epistaxis can be managed with packing or nasal
spray .
Question 3
The nurse is caring for a client on continuous cardiac monitoring. Which task can be safely
delegated to an unlicensed assistive personnel (UAP)?
A. Document heart rate every hour from the monitor
B. Interpret rhythm changes
C. Obtain a 12-lead ECG
D. Initiate synchronized cardioversion
Correct Answer: A. Document heart rate every hour from the monitor
Rationale: UAPs may collect and document routine data such as heart rate from a monitor.
Interpretation of rhythms, obtaining 12-lead ECGs, and initiating synchronized cardioversion
require licensed nursing judgment and skill .
Question 4
A client with hypertensive crisis (BP 220/130 mmHg) is started on nicardipine 5 mg/hr IV. Two
minutes after initiation, the BP is 218/128 mmHg. What is the nurse's best action?
A. Increase drip to 7.5 mg/hr
B. Notify provider immediately
C. Recheck BP in 5 minutes using the same cuff
D. Place client in Trendelenburg position
Correct Answer: C. Recheck BP in 5 minutes using the same cuff
Rationale: Rapid-acting vasodilators require 5–15 minutes for full effect. The nurse should
recheck per protocol before titrating. Trendelenburg worsens cerebral perfusion and is
contraindicated in hypertensive crisis .
,Question 5
A client is discharged on warfarin 5 mg daily. Which statement indicates correct understanding?
A. "I will take aspirin if I have chest pain."
B. "I should eat a spinach salad every day."
C. "I will check my INR every month."
D. "I will use an electric razor."
Correct Answer: D. "I will use an electric razor."
Rationale: An electric razor prevents bleeding injury. Daily spinach (vitamin K) would
destabilize INR; aspirin increases bleeding risk; INR is checked more frequently initially, then
weekly to monthly once stable .
Question 6
The monitor shows PR 0.28 seconds, regular RR, QRS 0.08 seconds. The nurse interprets this as:
A. First-degree AV block
B. Second-degree AV block Type I
C. Second-degree AV block Type II
D. Third-degree AV block
Correct Answer: A. First-degree AV block
Rationale: A PR interval greater than 0.20 seconds with a regular rhythm and normal QRS
indicates first-degree AV block. The PR interval is prolonged but all impulses are conducted .
Question 7
A nurse is assessing a client who is 4 hours postoperative following a subtotal thyroidectomy.
The client reports tingling in the fingers and around the mouth. Which action should the nurse
take first?
A. Assess the surgical dressing for bleeding
B. Check for Chvostek's sign
C. Administer an oral calcium supplement
D. Request a prescription for an opioid analgesic
Correct Answer: B. Check for Chvostek's sign
, Rationale: Circumoral paresthesia and tingling in the fingers are classic early signs of
hypocalcemia, a potential complication of thyroidectomy if parathyroid glands were damaged.
Checking for Chvostek's sign confirms hypocalcemia. The nurse must verify this clinical cue
before interventions .
Question 8
A nurse in the emergency department is caring for a client who reports crushing chest pain
radiating to the left arm. The 12-lead ECG shows ST-segment elevation in leads V1 through V4.
Which intervention is the absolute priority?
A. Administer morphine sulfate IV
B. Administer oxygen therapy if saturation is below 90%
C. Administer chewable aspirin
D. Obtain blood samples for cardiac enzymes
Correct Answer: C. Administer chewable aspirin
Rationale: In acute MI (STEMI), platelet aggregation must be inhibited immediately to
prevent further occlusion. While oxygen, morphine, and labs are important, administering
chewable aspirin has the most significant immediate impact on reducing mortality .
Question 9
A nurse is assessing a client with a history of left-sided heart failure. Which clinical finding
should the nurse expect?
A. Jugular venous distention
B. Dependent pitting edema
C. Hepatomegaly
D. Oliguria during the day
Correct Answer: D. Oliguria during the day
Rationale: Left-sided heart failure causes decreased cardiac output and reduced renal
perfusion during waking hours, leading to daytime oliguria. Options A, B, and C are signs of
right-sided heart failure .
