ATI
NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
, ATI MEDICAL-SURGICAL NURSING COMPREHENSIVE REVIEW
SECTION 1: Cardiovascular
1. A nurse is caring for a client who is receiving IV heparin for a deep vein
thrombosis. Which laboratory value should the nurse monitor to evaluate the
effectiveness of therapy?
• Answer: C. Activated partial thromboplastin time (aPTT)
• Rationale: aPTT is used to monitor and titrate unfractionated IV heparin
therapy (therapeutic range is typically 1.5–2.5x control). PT/INR are used
for warfarin. Platelet count is monitored for heparin-induced
thrombocytopenia but doesn't indicate therapeutic effectiveness.
2. A client with heart failure is prescribed furosemide. Which finding should the
nurse report to the provider immediately?
• Answer: A. Serum potassium 3.0 mEq/L
• Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
level of 3.0 mEq/L is below normal (3.5–5.0 mEq/L) and increases risk for
dangerous dysrhythmias.
,3. Which statement by a client recovering from an MI indicates a need for
further teaching about nitroglycerin use?
• Answer: C. "I should keep taking it as long as chest pain continues, even
after 3 doses."
• Rationale: Clients should call 911 if pain is not relieved after 1 tablet in 5
minutes. They should take no more than 3 tablets total while awaiting EMS.
4. A nurse is assessing a client with suspected cardiac tamponade. Which
findings should the nurse expect? (Select all that apply.)
• Answer: A, B, C, E (Muffled heart sounds, JVD, Hypotension, Pulsus
paradoxus)
• Rationale: Cardiac tamponade classically presents with Beck's triad
(muffled heart sounds, JVD, hypotension) plus pulsus paradoxus.
Tachycardia, not bradycardia, is expected.
5. A client is 2 hours post-cardiac catheterization via the right femoral approach.
Which finding requires immediate nursing intervention?
• Answer: C. Right foot cool and pale with absent pedal pulse
, • Rationale: A cool, pale extremity with absent pulses distal to the site
suggests arterial occlusion or hematoma and is a medical emergency.
SECTION 2: Respiratory
6. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Which finding indicates the system is functioning correctly?
• Answer: B. Tidaling (fluctuation) in the water-seal chamber with
respirations
• Rationale: Tidaling indicates the system is patent. Continuous bubbling
suggests an air leak; absence of fluctuation may indicate obstruction or lung
re-expansion.
7. A client with COPD has an oxygen saturation of 88% on room air. What is the
priority nursing action?
• Answer: A. Administer oxygen at 2 L/min via nasal cannula and reassess
• Rationale: Low-flow oxygen is used in COPD to avoid suppressing the
hypoxic respiratory drive. Oxygen should never be withheld from a hypoxic
client; titrate cautiously.
NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
, ATI MEDICAL-SURGICAL NURSING COMPREHENSIVE REVIEW
SECTION 1: Cardiovascular
1. A nurse is caring for a client who is receiving IV heparin for a deep vein
thrombosis. Which laboratory value should the nurse monitor to evaluate the
effectiveness of therapy?
• Answer: C. Activated partial thromboplastin time (aPTT)
• Rationale: aPTT is used to monitor and titrate unfractionated IV heparin
therapy (therapeutic range is typically 1.5–2.5x control). PT/INR are used
for warfarin. Platelet count is monitored for heparin-induced
thrombocytopenia but doesn't indicate therapeutic effectiveness.
2. A client with heart failure is prescribed furosemide. Which finding should the
nurse report to the provider immediately?
• Answer: A. Serum potassium 3.0 mEq/L
• Rationale: Furosemide is a loop diuretic that causes potassium wasting. A
level of 3.0 mEq/L is below normal (3.5–5.0 mEq/L) and increases risk for
dangerous dysrhythmias.
,3. Which statement by a client recovering from an MI indicates a need for
further teaching about nitroglycerin use?
• Answer: C. "I should keep taking it as long as chest pain continues, even
after 3 doses."
• Rationale: Clients should call 911 if pain is not relieved after 1 tablet in 5
minutes. They should take no more than 3 tablets total while awaiting EMS.
4. A nurse is assessing a client with suspected cardiac tamponade. Which
findings should the nurse expect? (Select all that apply.)
• Answer: A, B, C, E (Muffled heart sounds, JVD, Hypotension, Pulsus
paradoxus)
• Rationale: Cardiac tamponade classically presents with Beck's triad
(muffled heart sounds, JVD, hypotension) plus pulsus paradoxus.
Tachycardia, not bradycardia, is expected.
5. A client is 2 hours post-cardiac catheterization via the right femoral approach.
Which finding requires immediate nursing intervention?
• Answer: C. Right foot cool and pale with absent pedal pulse
, • Rationale: A cool, pale extremity with absent pulses distal to the site
suggests arterial occlusion or hematoma and is a medical emergency.
SECTION 2: Respiratory
6. A nurse is caring for a client with a chest tube connected to a water-seal
drainage system. Which finding indicates the system is functioning correctly?
• Answer: B. Tidaling (fluctuation) in the water-seal chamber with
respirations
• Rationale: Tidaling indicates the system is patent. Continuous bubbling
suggests an air leak; absence of fluctuation may indicate obstruction or lung
re-expansion.
7. A client with COPD has an oxygen saturation of 88% on room air. What is the
priority nursing action?
• Answer: A. Administer oxygen at 2 L/min via nasal cannula and reassess
• Rationale: Low-flow oxygen is used in COPD to avoid suppressing the
hypoxic respiratory drive. Oxygen should never be withheld from a hypoxic
client; titrate cautiously.
