ATI RN Adult Medical-Surgical
Nursing: Practice Questions with
Rationales
Cardiovascular Disorders (Questions 1-30)
1. A nurse is assessing a client with right-sided heart failure. Which
finding should the nurse expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
C) Jugular venous distension (JVD)
D) Frothy sputum
Answer: C) Jugular venous distension
Rationale: Right-sided heart failure causes systemic venous backup leading
to JVD, peripheral edema, and hepatomegaly. Crackles, PND, and frothy
sputum indicate left-sided failure .
2. A client with heart failure reports sudden onset of dyspnea and
coughing up pink, frothy sputum. Which action should the nurse take
FIRST?
A) Administer furosemide IV push
B) Apply oxygen via non-rebreather mask
,C) Place the client in high-Fowler's position
D) Notify the healthcare provider immediately
Answer: C) Place the client in high-Fowler's position
Rationale: Positioning the client upright reduces venous return and
pulmonary congestion, which is the priority intervention for acute
pulmonary edema before other treatments are initiated .
3. A client with heart failure is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss (hypokalemia). Hypokalemia can lead to cardiac
arrhythmias, especially in clients with heart failure who may also be taking
digoxin .
4. A client with heart failure reports gaining 4 pounds in 2 days. What
is the nurse's PRIORITY action?
,A) Document the finding
B) Notify the provider
C) Encourage fluid intake
D) Provide diet education
Answer: B) Notify the provider
Rationale: Rapid weight gain (2+ pounds in 24 hours or 5+ pounds in a
week) indicates fluid overload in a client with heart failure and requires
provider notification for potential medication adjustment .
5. A client with heart failure on digoxin reports nausea and yellow-
tinged vision. What is the nurse's priority action?
A) Administer digoxin immune Fab
B) Check the digoxin level
C) Give the next dose as ordered
D) Encourage oral fluids
Answer: B) Check the digoxin level
Rationale: Nausea and yellow vision are signs of digoxin toxicity. The nurse
should check the digoxin level before notifying the provider .
6. A client is scheduled for cardiac catheterization. Which assessment is
most important prior to the procedure?
, A) Allergies to contrast dye or shellfish
B) Last oral intake
C) Current medications
D) Vital signs
Answer: A) Allergies to contrast dye or shellfish
Rationale: The contrast dye used during cardiac catheterization contains
iodine, and clients with shellfish allergies may have a cross-sensitivity
reaction. This is a critical safety assessment .
7. A client receiving IV heparin has a partial thromboplastin time (PTT)
of 90 seconds. The normal range is 25-35 seconds. What action should
the nurse take?
A) Continue heparin at current dose
B) Notify the provider immediately
C) Hold the heparin dose
D) Administer protamine sulfate
Answer: B) Notify the provider immediately
Rationale: A PTT of 90 seconds indicates significantly increased bleeding
risk. The provider must adjust the dose. While holding the dose may be
appropriate, notifying the provider is the priority action for medication
adjustment .
Nursing: Practice Questions with
Rationales
Cardiovascular Disorders (Questions 1-30)
1. A nurse is assessing a client with right-sided heart failure. Which
finding should the nurse expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
C) Jugular venous distension (JVD)
D) Frothy sputum
Answer: C) Jugular venous distension
Rationale: Right-sided heart failure causes systemic venous backup leading
to JVD, peripheral edema, and hepatomegaly. Crackles, PND, and frothy
sputum indicate left-sided failure .
2. A client with heart failure reports sudden onset of dyspnea and
coughing up pink, frothy sputum. Which action should the nurse take
FIRST?
A) Administer furosemide IV push
B) Apply oxygen via non-rebreather mask
,C) Place the client in high-Fowler's position
D) Notify the healthcare provider immediately
Answer: C) Place the client in high-Fowler's position
Rationale: Positioning the client upright reduces venous return and
pulmonary congestion, which is the priority intervention for acute
pulmonary edema before other treatments are initiated .
3. A client with heart failure is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Answer: B) Serum potassium
Rationale: Furosemide is a loop diuretic that can cause significant
potassium loss (hypokalemia). Hypokalemia can lead to cardiac
arrhythmias, especially in clients with heart failure who may also be taking
digoxin .
4. A client with heart failure reports gaining 4 pounds in 2 days. What
is the nurse's PRIORITY action?
,A) Document the finding
B) Notify the provider
C) Encourage fluid intake
D) Provide diet education
Answer: B) Notify the provider
Rationale: Rapid weight gain (2+ pounds in 24 hours or 5+ pounds in a
week) indicates fluid overload in a client with heart failure and requires
provider notification for potential medication adjustment .
5. A client with heart failure on digoxin reports nausea and yellow-
tinged vision. What is the nurse's priority action?
A) Administer digoxin immune Fab
B) Check the digoxin level
C) Give the next dose as ordered
D) Encourage oral fluids
Answer: B) Check the digoxin level
Rationale: Nausea and yellow vision are signs of digoxin toxicity. The nurse
should check the digoxin level before notifying the provider .
6. A client is scheduled for cardiac catheterization. Which assessment is
most important prior to the procedure?
, A) Allergies to contrast dye or shellfish
B) Last oral intake
C) Current medications
D) Vital signs
Answer: A) Allergies to contrast dye or shellfish
Rationale: The contrast dye used during cardiac catheterization contains
iodine, and clients with shellfish allergies may have a cross-sensitivity
reaction. This is a critical safety assessment .
7. A client receiving IV heparin has a partial thromboplastin time (PTT)
of 90 seconds. The normal range is 25-35 seconds. What action should
the nurse take?
A) Continue heparin at current dose
B) Notify the provider immediately
C) Hold the heparin dose
D) Administer protamine sulfate
Answer: B) Notify the provider immediately
Rationale: A PTT of 90 seconds indicates significantly increased bleeding
risk. The provider must adjust the dose. While holding the dose may be
appropriate, notifying the provider is the priority action for medication
adjustment .
