ATI MedIcAl-SurgIcAl exAM: 100%
cOrrecT QueSTIOnS wITh AnSwerS &
rATIOnAleS lATTeST YeAr 2025-2026
1. A nurse is assessing a client who is 6 hours post-operative following a cardiac
catheterization via the femoral artery. Which finding requires immediate intervention?
A) Blood pressure 110/70 mm Hg
B) Heart rate 88 bpm
C) Pallor and coolness of the right foot
D) Small amount of serous drainage at the insertion site
Answer: C
Rationale: Pallor and coolness of the extremity indicate arterial insufficiency, possibly from a
thrombus or hematoma compressing the artery. This is a critical finding requiring immediate
intervention to prevent limb loss. The other options are expected or non-urgent findings .
2. A nurse is caring for a client with heart failure who has a new prescription for furosemide
(Lasix). Which laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting through increased
1
, urinary excretion. Hypokalemia (low potassium) can precipitate cardiac dysrhythmias, especially
in clients taking digoxin. Potassium levels should be monitored closely .
3. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value is
most important to monitor?
A) Platelet count
B) Hemoglobin
C) INR
D) aPTT
Answer: C
Rationale: The International Normalized Ratio (INR) monitors the effectiveness and safety of
warfarin therapy. The therapeutic range for atrial fibrillation is typically 2.0-3.0. aPTT is used for
heparin monitoring .
4. A nurse administers nitroglycerin sublingually to a client with chest pain. Which outcome
indicates the medication is effective?
A) Increased heart rate
B) Relief of chest pain
C) Decreased urine output
D) Elevated blood pressure
Answer: B
Rationale: Nitroglycerin dilates coronary arteries, increasing oxygen supply to the myocardium
and relieving chest pain. Relief of chest pain is the desired therapeutic outcome .
5. Which statement by a client with angina indicates understanding of nitroglycerin sublingual
administration?
A) "I will take one tablet every 5 minutes until the pain is gone, up to 3 tablets."
B) "I will swallow the tablet with a full glass of water."
C) "I will call 911 immediately if one tablet does not relieve my pain."
D) "I will take a tablet before exercise to prevent chest pain."
Answer: D
Rationale: Nitroglycerin can be used prophylactically before activities that may provoke angina.
2
, For acute pain: take one tablet; if pain persists after 5 minutes, call 911 and take a second tablet
while waiting. Tablets are placed under the tongue, not swallowed .
6. A nurse is caring for a client following a myocardial infarction (MI). Which medication is
prescribed to prevent further thrombus formation?
A) Metoprolol (Lopressor)
B) Lisinopril (Zestril)
C) Aspirin
D) Atorvastatin (Lipitor)
Answer: C
Rationale: Aspirin inhibits platelet aggregation and reduces the risk of recurrent MI. Metoprolol
reduces cardiac workload, lisinopril reduces afterload, and atorvastatin lowers cholesterol—all
are part of post-MI therapy, but aspirin specifically prevents thrombus formation .
7. A nurse is assessing a client with left-sided heart failure. Which finding is most indicative?
A) Jugular venous distention
B) Peripheral edema
C) Crackles in the lung bases
D) Hepatomegaly
Answer: C
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles (rales),
dyspnea, and cough. The other findings (JVD, peripheral edema, hepatomegaly) are
characteristic of right-sided heart failure .
8. A nurse is caring for a client with pericarditis. Which finding is most characteristic?
A) Chest pain that worsens when lying flat
B) Chest pain that is relieved by leaning forward
C) A friction rub heard at the left sternal border
D) All of the above
Answer: D
Rationale: Pericarditis typically causes sharp, pleuritic chest pain that worsens when supine and
improves when leaning forward. A pericardial friction rub is a classic auscultatory finding .
3
, 9. A nurse is assessing a client with infective endocarditis. Which manifestations should the
nurse expect to find? (Select all that apply)
A) Osler's nodes
B) Janeway lesions
C) Splinter hemorrhages
D) Roth spots
E) Positive Homans' sign
Answer: A, B, C, D
Rationale: Infective endocarditis presents with peripheral manifestations of embolic
phenomena: Osler's nodes (tender nodules on fingers/toes), Janeway lesions (non-tender
macules on palms/soles), splinter hemorrhages (linear streaks under nails), and Roth spots
(retinal hemorrhages). Positive Homans' sign is associated with DVT .
High-Yield Tip: "FROM JANE" – Fever, Roth spots, Osler's nodes, Murmur, Janeway lesions,
Anemia, Nail splinter hemorrhages, Emboli .
10. A nurse is providing discharge teaching to a client with heart failure. Which statement
indicates understanding?
A) "I will weigh myself once a week at the same time of day."
B) "I should limit my fluid intake to 3 liters per day."
C) "I will call my doctor if I gain more than 2-3 pounds in a day."
D) "I can stop my medications if I feel better."
Answer: C
Rationale: Daily weights are essential for heart failure management. A weight gain of 2-3
pounds in 24 hours indicates fluid retention and should be reported. Weighing should be done
daily, not weekly .
11. A client is receiving a continuous heparin infusion. Which laboratory value should the
nurse monitor?
A) INR
B) aPTT
C) Platelet count
D) Hemoglobin
4
cOrrecT QueSTIOnS wITh AnSwerS &
rATIOnAleS lATTeST YeAr 2025-2026
1. A nurse is assessing a client who is 6 hours post-operative following a cardiac
catheterization via the femoral artery. Which finding requires immediate intervention?
A) Blood pressure 110/70 mm Hg
B) Heart rate 88 bpm
C) Pallor and coolness of the right foot
D) Small amount of serous drainage at the insertion site
Answer: C
Rationale: Pallor and coolness of the extremity indicate arterial insufficiency, possibly from a
thrombus or hematoma compressing the artery. This is a critical finding requiring immediate
intervention to prevent limb loss. The other options are expected or non-urgent findings .
2. A nurse is caring for a client with heart failure who has a new prescription for furosemide
(Lasix). Which laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium wasting through increased
1
, urinary excretion. Hypokalemia (low potassium) can precipitate cardiac dysrhythmias, especially
in clients taking digoxin. Potassium levels should be monitored closely .
3. A client with atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value is
most important to monitor?
A) Platelet count
B) Hemoglobin
C) INR
D) aPTT
Answer: C
Rationale: The International Normalized Ratio (INR) monitors the effectiveness and safety of
warfarin therapy. The therapeutic range for atrial fibrillation is typically 2.0-3.0. aPTT is used for
heparin monitoring .
4. A nurse administers nitroglycerin sublingually to a client with chest pain. Which outcome
indicates the medication is effective?
A) Increased heart rate
B) Relief of chest pain
C) Decreased urine output
D) Elevated blood pressure
Answer: B
Rationale: Nitroglycerin dilates coronary arteries, increasing oxygen supply to the myocardium
and relieving chest pain. Relief of chest pain is the desired therapeutic outcome .
5. Which statement by a client with angina indicates understanding of nitroglycerin sublingual
administration?
A) "I will take one tablet every 5 minutes until the pain is gone, up to 3 tablets."
B) "I will swallow the tablet with a full glass of water."
C) "I will call 911 immediately if one tablet does not relieve my pain."
D) "I will take a tablet before exercise to prevent chest pain."
Answer: D
Rationale: Nitroglycerin can be used prophylactically before activities that may provoke angina.
2
, For acute pain: take one tablet; if pain persists after 5 minutes, call 911 and take a second tablet
while waiting. Tablets are placed under the tongue, not swallowed .
6. A nurse is caring for a client following a myocardial infarction (MI). Which medication is
prescribed to prevent further thrombus formation?
A) Metoprolol (Lopressor)
B) Lisinopril (Zestril)
C) Aspirin
D) Atorvastatin (Lipitor)
Answer: C
Rationale: Aspirin inhibits platelet aggregation and reduces the risk of recurrent MI. Metoprolol
reduces cardiac workload, lisinopril reduces afterload, and atorvastatin lowers cholesterol—all
are part of post-MI therapy, but aspirin specifically prevents thrombus formation .
7. A nurse is assessing a client with left-sided heart failure. Which finding is most indicative?
A) Jugular venous distention
B) Peripheral edema
C) Crackles in the lung bases
D) Hepatomegaly
Answer: C
Rationale: Left-sided heart failure leads to pulmonary congestion, causing crackles (rales),
dyspnea, and cough. The other findings (JVD, peripheral edema, hepatomegaly) are
characteristic of right-sided heart failure .
8. A nurse is caring for a client with pericarditis. Which finding is most characteristic?
A) Chest pain that worsens when lying flat
B) Chest pain that is relieved by leaning forward
C) A friction rub heard at the left sternal border
D) All of the above
Answer: D
Rationale: Pericarditis typically causes sharp, pleuritic chest pain that worsens when supine and
improves when leaning forward. A pericardial friction rub is a classic auscultatory finding .
3
, 9. A nurse is assessing a client with infective endocarditis. Which manifestations should the
nurse expect to find? (Select all that apply)
A) Osler's nodes
B) Janeway lesions
C) Splinter hemorrhages
D) Roth spots
E) Positive Homans' sign
Answer: A, B, C, D
Rationale: Infective endocarditis presents with peripheral manifestations of embolic
phenomena: Osler's nodes (tender nodules on fingers/toes), Janeway lesions (non-tender
macules on palms/soles), splinter hemorrhages (linear streaks under nails), and Roth spots
(retinal hemorrhages). Positive Homans' sign is associated with DVT .
High-Yield Tip: "FROM JANE" – Fever, Roth spots, Osler's nodes, Murmur, Janeway lesions,
Anemia, Nail splinter hemorrhages, Emboli .
10. A nurse is providing discharge teaching to a client with heart failure. Which statement
indicates understanding?
A) "I will weigh myself once a week at the same time of day."
B) "I should limit my fluid intake to 3 liters per day."
C) "I will call my doctor if I gain more than 2-3 pounds in a day."
D) "I can stop my medications if I feel better."
Answer: C
Rationale: Daily weights are essential for heart failure management. A weight gain of 2-3
pounds in 24 hours indicates fluid retention and should be reported. Weighing should be done
daily, not weekly .
11. A client is receiving a continuous heparin infusion. Which laboratory value should the
nurse monitor?
A) INR
B) aPTT
C) Platelet count
D) Hemoglobin
4
