ATI Med-Surg II (Medical-Surgical Nursing 2) –
Nursing Program – Exam-Style Questions with
Detailed Rationales and Answers (2024 -2025)
ATI Med-Surg II – Comprehensive Exam
Cardiovascular Disorders
1. A nurse is assessing a client with heart failure who has been prescribed digoxin. Which
finding requires immediate intervention?
A. Apical heart rate of 58 bpm
B. Serum potassium level of 3.2 mEq/L
C. Complaints of blurred yellow vision
D. Pedal edema +2
Answer: C
Rationale: Blurred yellow vision (xanthopsia) is a classic sign of digoxin toxicity, which can
lead to life-threatening dysrhythmias. Hypokalemia (B) predisposes to toxicity but the visual
change is a direct sign of toxicity. HR 58 is expected for digoxin effect. Edema indicates
failure but not acute toxicity.
2. A client with unstable angina is receiving heparin infusion. Which laboratory value
indicates the heparin is therapeutic?
A. aPTT 2.5 times the control
B. INR 3.0
C. Platelet count 50,000/mm³
D. PT 12 seconds
Answer: A
Rationale: For heparin, therapeutic range is aPTT 1.5–2.5 times normal control. INR
monitors warfarin. Low platelets suggest HIT. PT monitors warfarin/extrinsic pathway.
3. Post-cardiac catheterization, the nurse finds the femoral access site bleeding. What is
the priority action?
A. Apply firm pressure 1 inch above the site
B. Apply a sandbag over the site
,C. Lower the head of the bed
D. Call the provider immediately
Answer: A
Rationale: Direct pressure above the arterial puncture site (to compress the artery against
bone) is first-line. Sandbags are outdated. Lowering HOB may increase bleeding. Calling
provider occurs after initial control.
4. A client with hypertension is started on lisinopril. Which adverse effect requires client
education?
A. Dry, nonproductive cough
B. Hypokalemia
C. Bradycardia
D. Constipation
Answer: A
Rationale: Lisinopril (ACE inhibitor) commonly causes a dry cough due to bradykinin
accumulation. It causes hyperkalemia (not hypokalemia). Bradycardia is not typical.
5. A client with peripheral artery disease (PAD) reports leg pain when walking that
resolves with rest. The nurse documents this as:
A. Rest pain
B. Venous insufficiency
C. Intermittent claudication
D. Neuropathic pain
Answer: C
Rationale: Intermittent claudication is muscle pain/cramping with exercise, relieved by rest,
due to inadequate blood flow in PAD.
Respiratory Disorders
6. A client with COPD has an SpO2 of 88% on 2 L/min oxygen. What is the nurse’s best
action?
A. Increase oxygen to 4 L/min
B. Maintain current oxygen
C. Apply a non-rebreather mask
D. Prepare for intubation
, Answer: B
Rationale: COPD clients rely on hypoxic drive. Target SpO2 88-92%. Increasing O2 may cause
CO2 retention and respiratory depression.
7. A client post-lobectomy has a chest tube to water seal drainage. Which finding indicates
a tension pneumothorax?
A. Bubbling in suction control chamber
B. Tracheal deviation to the opposite side
C. Fluctuation in water seal chamber
D. Serosanguinous drainage in collection chamber
Answer: B
Rationale: Tension pneumothorax causes mediastinal shift, tracheal deviation AWAY from
affected side. Bubbling in suction is normal. Fluctuation (tidaling) is normal. Drainage is
expected.
8. A client with asthma is using a peak flow meter. Which zone indicates a need for
immediate bronchodilator?
A. Green zone (80-100% of personal best)
B. Yellow zone (50-80%)
C. Red zone (<50%)
D. Blue zone (100%)
Answer: C
Rationale: Red zone (<50%) indicates severe airway narrowing, requires immediate rescue
bronchodilator and possibly medical attention. Yellow zone means caution. Green is good
control.
9. A nurse is caring for a client with pulmonary embolism (PE). Which finding is most
concerning?
A. Respiratory rate 22
B. Oxygen saturation 91% on 2 L
C. Sudden onset of chest pain and hypotension
D. Heart rate 100 bpm
Answer: C
Rationale: Sudden chest pain with hypotension suggests massive PE causing decreased
cardiac output, high mortality. The other findings are less critical.
Nursing Program – Exam-Style Questions with
Detailed Rationales and Answers (2024 -2025)
ATI Med-Surg II – Comprehensive Exam
Cardiovascular Disorders
1. A nurse is assessing a client with heart failure who has been prescribed digoxin. Which
finding requires immediate intervention?
A. Apical heart rate of 58 bpm
B. Serum potassium level of 3.2 mEq/L
C. Complaints of blurred yellow vision
D. Pedal edema +2
Answer: C
Rationale: Blurred yellow vision (xanthopsia) is a classic sign of digoxin toxicity, which can
lead to life-threatening dysrhythmias. Hypokalemia (B) predisposes to toxicity but the visual
change is a direct sign of toxicity. HR 58 is expected for digoxin effect. Edema indicates
failure but not acute toxicity.
2. A client with unstable angina is receiving heparin infusion. Which laboratory value
indicates the heparin is therapeutic?
A. aPTT 2.5 times the control
B. INR 3.0
C. Platelet count 50,000/mm³
D. PT 12 seconds
Answer: A
Rationale: For heparin, therapeutic range is aPTT 1.5–2.5 times normal control. INR
monitors warfarin. Low platelets suggest HIT. PT monitors warfarin/extrinsic pathway.
3. Post-cardiac catheterization, the nurse finds the femoral access site bleeding. What is
the priority action?
A. Apply firm pressure 1 inch above the site
B. Apply a sandbag over the site
,C. Lower the head of the bed
D. Call the provider immediately
Answer: A
Rationale: Direct pressure above the arterial puncture site (to compress the artery against
bone) is first-line. Sandbags are outdated. Lowering HOB may increase bleeding. Calling
provider occurs after initial control.
4. A client with hypertension is started on lisinopril. Which adverse effect requires client
education?
A. Dry, nonproductive cough
B. Hypokalemia
C. Bradycardia
D. Constipation
Answer: A
Rationale: Lisinopril (ACE inhibitor) commonly causes a dry cough due to bradykinin
accumulation. It causes hyperkalemia (not hypokalemia). Bradycardia is not typical.
5. A client with peripheral artery disease (PAD) reports leg pain when walking that
resolves with rest. The nurse documents this as:
A. Rest pain
B. Venous insufficiency
C. Intermittent claudication
D. Neuropathic pain
Answer: C
Rationale: Intermittent claudication is muscle pain/cramping with exercise, relieved by rest,
due to inadequate blood flow in PAD.
Respiratory Disorders
6. A client with COPD has an SpO2 of 88% on 2 L/min oxygen. What is the nurse’s best
action?
A. Increase oxygen to 4 L/min
B. Maintain current oxygen
C. Apply a non-rebreather mask
D. Prepare for intubation
, Answer: B
Rationale: COPD clients rely on hypoxic drive. Target SpO2 88-92%. Increasing O2 may cause
CO2 retention and respiratory depression.
7. A client post-lobectomy has a chest tube to water seal drainage. Which finding indicates
a tension pneumothorax?
A. Bubbling in suction control chamber
B. Tracheal deviation to the opposite side
C. Fluctuation in water seal chamber
D. Serosanguinous drainage in collection chamber
Answer: B
Rationale: Tension pneumothorax causes mediastinal shift, tracheal deviation AWAY from
affected side. Bubbling in suction is normal. Fluctuation (tidaling) is normal. Drainage is
expected.
8. A client with asthma is using a peak flow meter. Which zone indicates a need for
immediate bronchodilator?
A. Green zone (80-100% of personal best)
B. Yellow zone (50-80%)
C. Red zone (<50%)
D. Blue zone (100%)
Answer: C
Rationale: Red zone (<50%) indicates severe airway narrowing, requires immediate rescue
bronchodilator and possibly medical attention. Yellow zone means caution. Green is good
control.
9. A nurse is caring for a client with pulmonary embolism (PE). Which finding is most
concerning?
A. Respiratory rate 22
B. Oxygen saturation 91% on 2 L
C. Sudden onset of chest pain and hypotension
D. Heart rate 100 bpm
Answer: C
Rationale: Sudden chest pain with hypotension suggests massive PE causing decreased
cardiac output, high mortality. The other findings are less critical.
