ATI RN MEDICAL SURGICAL
ACTUAL PROCTORED EXAM
180 NGN Questions
Detailed Answer Key Included
SECTION BREAKDOWN
Q1 - Q35 CARDIOVASCULAR SYSTEM
Q36 - Q60 RESPIRATORY SYSTEM
Q61 - Q85 NEUROLOGICAL SYSTEM
Q86 - Q105 RENAL AND GENITOURINARY SYSTEM
Q106 - Q125 GASTROINTESTINAL SYSTEM
Q126 - Q145 ENDOCRINE SYSTEM
Q146 - Q160 HEMATOLOGIC AND IMMUNOLOGIC SYSTEM
Q161 - Q180 MUSCULOSKELETAL, INTEGUMENTARY, AND MULTISYSTEM
,ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
SECTION: CARDIOVASCULAR SYSTEM
Questions 1 - 35
1. A nurse is caring for a client who was admitted 2 hours ago with a suspected acute myocardial infarction (AMI). The client's
troponin I level is 0.03 ng/mL. Which of the following actions should the nurse take?
A. Prepare the client for immediate cardiac catheterization
B. Instruct the client that the result indicates no myocardial damage
C. Recognize that a second troponin specimen is needed in 3 to 6 hours [CORRECT]
D. Administer prescribed sublingual nitroglycerin for chest pain
Correct Answer: C
Rationale: Troponin I is a highly specific cardiac biomarker that rises within 2 to 4 hours after myocardial injury, peaks at 12 to 24 hours, and
remains elevated for 7 to 10 days. A single troponin of 0.03 ng/mL is within an indeterminate or early-elevation range depending on the
laboratory reference, and serial sampling is required to identify the characteristic rise-and-fall pattern diagnostic of AMI. The nurse should
anticipate drawing a second specimen 3 to 6 hours after the first. A single normal or borderline value does not rule out AMI because the enzyme
may not have risen yet. Cardiac catheterization is not indicated based on a single borderline troponin without corroborating ECG changes. The
nurse should not interpret the result as definitively negative. While nitroglycerin may be prescribed for chest pain, the question focuses on the
troponin result interpretation, and the priority is ensuring appropriate serial monitoring rather than a single intervention.
2. A nurse is assessing a client who is 6 hours postoperative following a coronary artery bypass graft (CABG). The nurse notes
the client's chest tube drainage has suddenly decreased from 150 mL/hr to 15 mL/hr over the past hour. Which of the following
actions is the nurse's priority?
A. Document the finding and continue monitoring
B. Milk the chest tube gently to restore drainage
C. Check for kinks or dependent loops in the tubing [CORRECT]
D. Notify the provider of potential cardiac tamponade
Correct Answer: C
Rationale: A sudden, significant decrease in chest tube drainage following CABG may indicate tube obstruction rather than a genuine reduction
in bleeding. The nurse should first assess the entire drainage system for kinks, clots, or dependent loops that could impede flow. Milking or
stripping chest tubes is generally contraindicated in many institutions because it generates excessive negative intrathoracic pressure that can
damage the suture lines or disrupt the graft sites. Once the tubing is confirmed patent and properly positioned, if drainage remains markedly
decreased accompanied by signs such as hypotension, jugular venous distention, muffled heart sounds, or equalization of pressures (Beck's
triad), the nurse should suspect cardiac tamponade and notify the provider immediately. However, the initial and priority action is to rule out a
mechanical cause for the decreased output before escalating.
3. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the
following statements by the client indicates an understanding of the teaching?
A. 'I will drink at least 3 liters of fluid every day.'
B. 'I will eat foods rich in potassium, such as bananas and oranges.' [CORRECT]
C. 'I will take this medication at bedtime to prevent dizziness.'
D. 'I will weigh myself once a week to monitor for fluid retention.'
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant urinary excretion of sodium, chloride, water, and potassium. Hypokalemia is a
common and potentially dangerous adverse effect that can lead to cardiac dysrhythmias, muscle weakness, and fatigue. Clients should be
instructed to consume potassium-rich foods such as bananas, oranges, raisins, potatoes, and spinach, or the provider may prescribe a potassium
supplement. Drinking 3 liters of fluid daily is contraindicated for heart failure clients because excessive fluid intake exacerbates fluid overload
and pulmonary congestion. Furosemide should be taken in the morning to prevent nocturia and sleep disruption; taking it at bedtime is
inappropriate. The client should weigh themselves daily, not weekly, at the same time each morning after voiding and before eating, and report
a weight gain of more than 1 to 2 kg in 24 hours to the provider.
4. A nurse is reviewing the laboratory results of a client who has chronic heart failure and is receiving digoxin. Which of the
following findings should the nurse report to the provider immediately?
A. Potassium 3.2 mEq/L [CORRECT]
B. Sodium 138 mEq/L
C. Magnesium 2.0 mEq/L
D. Calcium 9.2 mg/dL
Correct Answer: A
Page 2 Detailed Answer Key Included
,ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
Rationale: Hypokalemia (potassium below 3.5 mEq/L) significantly increases the risk of digoxin toxicity. Digoxin and potassium compete for the
same binding site on the Na+/K+-ATPase pump; when potassium levels are low, digoxin binds more extensively to the pump, intensifying its
inhibitory effect on sodium-potassium exchange and leading to enhanced automaticity and ectopic pacemaker activity. A potassium level of 3.2
mEq/L is below the normal range of 3.5 to 5.0 mEq/L and requires immediate notification so that the provider can prescribe potassium
replacement or adjust the digoxin dose. Early signs of digoxin toxicity include anorexia, nausea, visual disturbances (halos, yellow-green vision),
and cardiac dysrhythmias such as premature ventricular contractions. The sodium, magnesium, and calcium values listed are within normal
limits.
5. A nurse is caring for a client who has a new diagnosis of peripheral arterial disease (PAD). The client asks why the pain in
their legs occurs when walking but is relieved by rest. Which of the following responses by the nurse is appropriate?
A. 'The muscles in your legs are not getting enough oxygen during exercise because of narrowed arteries.' [CORRECT]
B. 'The veins in your legs have valves that are not functioning properly, causing blood to pool.'
C. 'Walking causes inflammation in the joints of your legs, which produces the pain you feel.'
D. 'The pain is caused by nerve compression in your lower spine when you stand upright.'
Correct Answer: A
Rationale: Peripheral arterial disease is caused by atherosclerotic narrowing of the arterial lumen, which reduces blood flow to the extremities.
During exercise, the metabolic demand of the muscles increases, requiring more oxygen delivery. When the arterial supply cannot meet this
increased demand due to stenosis, ischemia develops, producing the characteristic cramping pain known as intermittent claudication. Resting
reduces metabolic demand, and the limited arterial supply becomes sufficient again, relieving the pain. Option B describes venous insufficiency,
not arterial disease. Option C refers to osteoarthritis or inflammatory joint conditions. Option D describes neurogenic claudication associated
with spinal stenosis, which is a different clinical entity from vascular claudication.
6. A nurse is assessing a client who is receiving heparin by continuous IV infusion for the treatment of a deep vein thrombosis
(DVT). The client's activated partial thromboplastin time (aPTT) is 95 seconds. Which of the following actions should the nurse
take?
A. Stop the heparin infusion immediately.
B. Administer protamine sulfate.
C. Reduce the infusion rate as prescribed. [CORRECT]
D. Continue the current infusion rate.
Correct Answer: C
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the laboratory control value, approximately 60 to
80 seconds for most institutions. An aPTT of 95 seconds exceeds the therapeutic range, indicating that the client is over-anticoagulated and is at
increased risk for bleeding. The appropriate action is to reduce the heparin infusion rate as prescribed (or per institutional protocol) and then
recheck the aPTT in a few hours. Stopping the infusion entirely and administering protamine sulfate would be indicated for severe
over-anticoagulation with active bleeding or an aPTT significantly above the therapeutic range (often greater than 100-120 seconds with
bleeding). Continuing the current rate would maintain the dangerous over-anticoagulated state. The nurse should also assess the client for signs
of bleeding such as hematuria, melena, ecchymosis, or neurological changes.
7. A nurse is caring for a client who had an automatic internal cardioverter-defibrillator (AICD) implanted 1 day ago. The client
expresses anxiety about the device firing. Which of the following responses by the nurse is most appropriate?
A. 'You should avoid all physical activity to prevent the device from discharging.'
B. 'If the device fires, sit down or lie down and have someone call your provider.' [CORRECT]
C. 'The device will not fire unless you are in a hospital setting where it can be monitored.'
D. 'Most clients do not feel anything when the device discharges.'
Correct Answer: B
Rationale: An AICD detects life-threatening ventricular dysrhythmias (ventricular tachycardia or ventricular fibrillation) and delivers a shock
to restore normal sinus rhythm. The client should be taught that if the device fires, they should sit or lie down to prevent injury from a possible
syncopal episode, and have someone contact their provider or call emergency services. One shock may be expected, but the client should seek
medical attention if multiple shocks occur, if they feel unwell after a shock, or if the shock does not terminate symptoms. Activity restrictions are
typically temporary (avoiding lifting the arm above shoulder level on the affected side for 4 to 6 weeks), but clients are not advised to avoid all
physical activity permanently. The device functions autonomously regardless of setting. Most clients do feel the shock, often describing it as a
sudden thump or jolt in the chest.
8. A nurse is monitoring a client following a myocardial infarction who reports new onset of a sharp, tearing chest pain that
radiates to the back. The client's blood pressure is 170/100 mm Hg in the right arm and 90/60 mm Hg in the left arm. Which of
the following complications should the nurse suspect?
A. Cardiac tamponade
B. Aortic dissection [CORRECT]
C. Pulmonary embolism
Page 3 Detailed Answer Key Included
, ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
D. Ventricular rupture
Correct Answer: B
Rationale: The classic presentation of aortic dissection includes sudden, severe, tearing or ripping chest or back pain, often described as the
worst pain the client has ever experienced. A blood pressure differential of greater than 20 mm Hg between arms is a key clinical finding that
suggests the dissection involves the subclavian artery. Hypertension is a major risk factor. The pain of cardiac tamponade is typically pleuritic
and positional, and the presentation includes Beck's triad (hypotension, jugular venous distention, muffled heart sounds) rather than blood
pressure asymmetry. Pulmonary embolism presents with dyspnea, pleuritic chest pain, tachycardia, and hypoxia, not blood pressure
differentials. Ventricular rupture, although a post-MI complication, presents with sudden cardiovascular collapse, not a blood pressure
discrepancy between arms. The nurse should notify the provider immediately and prepare for a STAT CT angiogram.
9. A nurse is caring for a client with heart failure who is receiving enalapril. Which of the following findings should the nurse
monitor as an adverse effect of this medication?
A. Hyperkalemia [CORRECT]
B. Bradycardia
C. Hypoglycemia
D. Constipation
Correct Answer: A
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that works by blocking the conversion of angiotensin I to angiotensin
II, reducing vasoconstriction and aldosterone secretion. Because aldosterone normally promotes potassium excretion in the kidneys, its reduction
leads to potassium retention. Therefore, hyperkalemia is a significant adverse effect that the nurse should monitor. The nurse should assess
serum potassium levels and observe for signs of hyperkalemia such as muscle weakness, paresthesias, and cardiac dysrhythmias. ACE inhibitors
more commonly cause a dry, persistent cough rather than constipation. Bradycardia is not a typical effect of ACE inhibitors; it is more
associated with beta-blockers. Hypoglycemia is not associated with enalapril. Additionally, the nurse should monitor for angioedema, a rare but
life-threatening adverse effect characterized by swelling of the face, lips, tongue, and throat.
10. A nurse is reviewing the electrocardiogram (ECG) rhythm strip of a client and identifies absent P waves, a variable PR
interval, and an irregularly irregular rhythm. The nurse should identify this as which of the following dysrhythmias?
A. Atrial flutter
B. Atrial fibrillation [CORRECT]
C. Second-degree atrioventricular (AV) block type I
D. Premature ventricular contractions (PVCs)
Correct Answer: B
Rationale: Atrial fibrillation is characterized by the absence of distinct P waves (replaced by chaotic, fibrillatory waves), an irregularly
irregular R-R interval, and a variable PR interval (because the AV node is bombarded by multiple atrial impulses at rates often exceeding 350
to 600 per minute). The AV node blocks most of these impulses, allowing only a variable number through to the ventricles, creating the classic
irregularly irregular pattern. Atrial flutter presents with characteristic sawtooth flutter waves (F waves) at a rate of 250 to 350 per minute,
often with a fixed conduction ratio (e.g., 2:1 or 4:1). Second-degree AV block type I (Wenckebach) shows progressively lengthening PR intervals
until a QRS complex is dropped, but with a regular underlying atrial rhythm. PVCs are premature, wide, bizarre QRS complexes that are not
preceded by a P wave, but the underlying rhythm remains regular between PVCs.
11. A nurse in the emergency department is caring for a client with a suspected ST-elevation myocardial infarction (STEMI).
The client's 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. The nurse should recognize that this indicates
infarction in which area of the heart?
A. Anterior wall
B. Lateral wall
C. Inferior wall [CORRECT]
D. Posterior wall
Correct Answer: C
Rationale: ST-segment elevation in leads II, III, and aVF is the hallmark of an inferior wall myocardial infarction. These leads face the
inferior (diaphragmatic) surface of the left ventricle. Anterior wall MI is indicated by ST elevation in leads V1 through V4. Lateral wall MI
shows ST elevation in leads I, aVL, V5, and V6. Posterior wall MI is suggested by ST depression in leads V1 through V3 (reciprocal changes)
and is often confirmed with posterior leads (V7, V8, V9). Recognizing the location of infarction is critical because different MI locations have
distinct complications: inferior MI is associated with bradycardia and heart block (because the right coronary artery also supplies the SA and
AV nodes), anterior MI is associated with ventricular dysrhythmias and heart failure, and lateral MI may involve the circumflex artery
territory.
12. A nurse is caring for a client who is 12 hours post-MI and develops sudden onset of dyspnea, bilateral crackles, and a pink
frothy sputum. The client's oxygen saturation is 88% on room air. Which of the following interventions should the nurse
implement first?
Page 4 Detailed Answer Key Included
ACTUAL PROCTORED EXAM
180 NGN Questions
Detailed Answer Key Included
SECTION BREAKDOWN
Q1 - Q35 CARDIOVASCULAR SYSTEM
Q36 - Q60 RESPIRATORY SYSTEM
Q61 - Q85 NEUROLOGICAL SYSTEM
Q86 - Q105 RENAL AND GENITOURINARY SYSTEM
Q106 - Q125 GASTROINTESTINAL SYSTEM
Q126 - Q145 ENDOCRINE SYSTEM
Q146 - Q160 HEMATOLOGIC AND IMMUNOLOGIC SYSTEM
Q161 - Q180 MUSCULOSKELETAL, INTEGUMENTARY, AND MULTISYSTEM
,ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
SECTION: CARDIOVASCULAR SYSTEM
Questions 1 - 35
1. A nurse is caring for a client who was admitted 2 hours ago with a suspected acute myocardial infarction (AMI). The client's
troponin I level is 0.03 ng/mL. Which of the following actions should the nurse take?
A. Prepare the client for immediate cardiac catheterization
B. Instruct the client that the result indicates no myocardial damage
C. Recognize that a second troponin specimen is needed in 3 to 6 hours [CORRECT]
D. Administer prescribed sublingual nitroglycerin for chest pain
Correct Answer: C
Rationale: Troponin I is a highly specific cardiac biomarker that rises within 2 to 4 hours after myocardial injury, peaks at 12 to 24 hours, and
remains elevated for 7 to 10 days. A single troponin of 0.03 ng/mL is within an indeterminate or early-elevation range depending on the
laboratory reference, and serial sampling is required to identify the characteristic rise-and-fall pattern diagnostic of AMI. The nurse should
anticipate drawing a second specimen 3 to 6 hours after the first. A single normal or borderline value does not rule out AMI because the enzyme
may not have risen yet. Cardiac catheterization is not indicated based on a single borderline troponin without corroborating ECG changes. The
nurse should not interpret the result as definitively negative. While nitroglycerin may be prescribed for chest pain, the question focuses on the
troponin result interpretation, and the priority is ensuring appropriate serial monitoring rather than a single intervention.
2. A nurse is assessing a client who is 6 hours postoperative following a coronary artery bypass graft (CABG). The nurse notes
the client's chest tube drainage has suddenly decreased from 150 mL/hr to 15 mL/hr over the past hour. Which of the following
actions is the nurse's priority?
A. Document the finding and continue monitoring
B. Milk the chest tube gently to restore drainage
C. Check for kinks or dependent loops in the tubing [CORRECT]
D. Notify the provider of potential cardiac tamponade
Correct Answer: C
Rationale: A sudden, significant decrease in chest tube drainage following CABG may indicate tube obstruction rather than a genuine reduction
in bleeding. The nurse should first assess the entire drainage system for kinks, clots, or dependent loops that could impede flow. Milking or
stripping chest tubes is generally contraindicated in many institutions because it generates excessive negative intrathoracic pressure that can
damage the suture lines or disrupt the graft sites. Once the tubing is confirmed patent and properly positioned, if drainage remains markedly
decreased accompanied by signs such as hypotension, jugular venous distention, muffled heart sounds, or equalization of pressures (Beck's
triad), the nurse should suspect cardiac tamponade and notify the provider immediately. However, the initial and priority action is to rule out a
mechanical cause for the decreased output before escalating.
3. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the
following statements by the client indicates an understanding of the teaching?
A. 'I will drink at least 3 liters of fluid every day.'
B. 'I will eat foods rich in potassium, such as bananas and oranges.' [CORRECT]
C. 'I will take this medication at bedtime to prevent dizziness.'
D. 'I will weigh myself once a week to monitor for fluid retention.'
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant urinary excretion of sodium, chloride, water, and potassium. Hypokalemia is a
common and potentially dangerous adverse effect that can lead to cardiac dysrhythmias, muscle weakness, and fatigue. Clients should be
instructed to consume potassium-rich foods such as bananas, oranges, raisins, potatoes, and spinach, or the provider may prescribe a potassium
supplement. Drinking 3 liters of fluid daily is contraindicated for heart failure clients because excessive fluid intake exacerbates fluid overload
and pulmonary congestion. Furosemide should be taken in the morning to prevent nocturia and sleep disruption; taking it at bedtime is
inappropriate. The client should weigh themselves daily, not weekly, at the same time each morning after voiding and before eating, and report
a weight gain of more than 1 to 2 kg in 24 hours to the provider.
4. A nurse is reviewing the laboratory results of a client who has chronic heart failure and is receiving digoxin. Which of the
following findings should the nurse report to the provider immediately?
A. Potassium 3.2 mEq/L [CORRECT]
B. Sodium 138 mEq/L
C. Magnesium 2.0 mEq/L
D. Calcium 9.2 mg/dL
Correct Answer: A
Page 2 Detailed Answer Key Included
,ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
Rationale: Hypokalemia (potassium below 3.5 mEq/L) significantly increases the risk of digoxin toxicity. Digoxin and potassium compete for the
same binding site on the Na+/K+-ATPase pump; when potassium levels are low, digoxin binds more extensively to the pump, intensifying its
inhibitory effect on sodium-potassium exchange and leading to enhanced automaticity and ectopic pacemaker activity. A potassium level of 3.2
mEq/L is below the normal range of 3.5 to 5.0 mEq/L and requires immediate notification so that the provider can prescribe potassium
replacement or adjust the digoxin dose. Early signs of digoxin toxicity include anorexia, nausea, visual disturbances (halos, yellow-green vision),
and cardiac dysrhythmias such as premature ventricular contractions. The sodium, magnesium, and calcium values listed are within normal
limits.
5. A nurse is caring for a client who has a new diagnosis of peripheral arterial disease (PAD). The client asks why the pain in
their legs occurs when walking but is relieved by rest. Which of the following responses by the nurse is appropriate?
A. 'The muscles in your legs are not getting enough oxygen during exercise because of narrowed arteries.' [CORRECT]
B. 'The veins in your legs have valves that are not functioning properly, causing blood to pool.'
C. 'Walking causes inflammation in the joints of your legs, which produces the pain you feel.'
D. 'The pain is caused by nerve compression in your lower spine when you stand upright.'
Correct Answer: A
Rationale: Peripheral arterial disease is caused by atherosclerotic narrowing of the arterial lumen, which reduces blood flow to the extremities.
During exercise, the metabolic demand of the muscles increases, requiring more oxygen delivery. When the arterial supply cannot meet this
increased demand due to stenosis, ischemia develops, producing the characteristic cramping pain known as intermittent claudication. Resting
reduces metabolic demand, and the limited arterial supply becomes sufficient again, relieving the pain. Option B describes venous insufficiency,
not arterial disease. Option C refers to osteoarthritis or inflammatory joint conditions. Option D describes neurogenic claudication associated
with spinal stenosis, which is a different clinical entity from vascular claudication.
6. A nurse is assessing a client who is receiving heparin by continuous IV infusion for the treatment of a deep vein thrombosis
(DVT). The client's activated partial thromboplastin time (aPTT) is 95 seconds. Which of the following actions should the nurse
take?
A. Stop the heparin infusion immediately.
B. Administer protamine sulfate.
C. Reduce the infusion rate as prescribed. [CORRECT]
D. Continue the current infusion rate.
Correct Answer: C
Rationale: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the laboratory control value, approximately 60 to
80 seconds for most institutions. An aPTT of 95 seconds exceeds the therapeutic range, indicating that the client is over-anticoagulated and is at
increased risk for bleeding. The appropriate action is to reduce the heparin infusion rate as prescribed (or per institutional protocol) and then
recheck the aPTT in a few hours. Stopping the infusion entirely and administering protamine sulfate would be indicated for severe
over-anticoagulation with active bleeding or an aPTT significantly above the therapeutic range (often greater than 100-120 seconds with
bleeding). Continuing the current rate would maintain the dangerous over-anticoagulated state. The nurse should also assess the client for signs
of bleeding such as hematuria, melena, ecchymosis, or neurological changes.
7. A nurse is caring for a client who had an automatic internal cardioverter-defibrillator (AICD) implanted 1 day ago. The client
expresses anxiety about the device firing. Which of the following responses by the nurse is most appropriate?
A. 'You should avoid all physical activity to prevent the device from discharging.'
B. 'If the device fires, sit down or lie down and have someone call your provider.' [CORRECT]
C. 'The device will not fire unless you are in a hospital setting where it can be monitored.'
D. 'Most clients do not feel anything when the device discharges.'
Correct Answer: B
Rationale: An AICD detects life-threatening ventricular dysrhythmias (ventricular tachycardia or ventricular fibrillation) and delivers a shock
to restore normal sinus rhythm. The client should be taught that if the device fires, they should sit or lie down to prevent injury from a possible
syncopal episode, and have someone contact their provider or call emergency services. One shock may be expected, but the client should seek
medical attention if multiple shocks occur, if they feel unwell after a shock, or if the shock does not terminate symptoms. Activity restrictions are
typically temporary (avoiding lifting the arm above shoulder level on the affected side for 4 to 6 weeks), but clients are not advised to avoid all
physical activity permanently. The device functions autonomously regardless of setting. Most clients do feel the shock, often describing it as a
sudden thump or jolt in the chest.
8. A nurse is monitoring a client following a myocardial infarction who reports new onset of a sharp, tearing chest pain that
radiates to the back. The client's blood pressure is 170/100 mm Hg in the right arm and 90/60 mm Hg in the left arm. Which of
the following complications should the nurse suspect?
A. Cardiac tamponade
B. Aortic dissection [CORRECT]
C. Pulmonary embolism
Page 3 Detailed Answer Key Included
, ATI RN Medical-Surgical Proctored Exam 2026/2027 180 NGN Questions | Detailed Answer Key
D. Ventricular rupture
Correct Answer: B
Rationale: The classic presentation of aortic dissection includes sudden, severe, tearing or ripping chest or back pain, often described as the
worst pain the client has ever experienced. A blood pressure differential of greater than 20 mm Hg between arms is a key clinical finding that
suggests the dissection involves the subclavian artery. Hypertension is a major risk factor. The pain of cardiac tamponade is typically pleuritic
and positional, and the presentation includes Beck's triad (hypotension, jugular venous distention, muffled heart sounds) rather than blood
pressure asymmetry. Pulmonary embolism presents with dyspnea, pleuritic chest pain, tachycardia, and hypoxia, not blood pressure
differentials. Ventricular rupture, although a post-MI complication, presents with sudden cardiovascular collapse, not a blood pressure
discrepancy between arms. The nurse should notify the provider immediately and prepare for a STAT CT angiogram.
9. A nurse is caring for a client with heart failure who is receiving enalapril. Which of the following findings should the nurse
monitor as an adverse effect of this medication?
A. Hyperkalemia [CORRECT]
B. Bradycardia
C. Hypoglycemia
D. Constipation
Correct Answer: A
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that works by blocking the conversion of angiotensin I to angiotensin
II, reducing vasoconstriction and aldosterone secretion. Because aldosterone normally promotes potassium excretion in the kidneys, its reduction
leads to potassium retention. Therefore, hyperkalemia is a significant adverse effect that the nurse should monitor. The nurse should assess
serum potassium levels and observe for signs of hyperkalemia such as muscle weakness, paresthesias, and cardiac dysrhythmias. ACE inhibitors
more commonly cause a dry, persistent cough rather than constipation. Bradycardia is not a typical effect of ACE inhibitors; it is more
associated with beta-blockers. Hypoglycemia is not associated with enalapril. Additionally, the nurse should monitor for angioedema, a rare but
life-threatening adverse effect characterized by swelling of the face, lips, tongue, and throat.
10. A nurse is reviewing the electrocardiogram (ECG) rhythm strip of a client and identifies absent P waves, a variable PR
interval, and an irregularly irregular rhythm. The nurse should identify this as which of the following dysrhythmias?
A. Atrial flutter
B. Atrial fibrillation [CORRECT]
C. Second-degree atrioventricular (AV) block type I
D. Premature ventricular contractions (PVCs)
Correct Answer: B
Rationale: Atrial fibrillation is characterized by the absence of distinct P waves (replaced by chaotic, fibrillatory waves), an irregularly
irregular R-R interval, and a variable PR interval (because the AV node is bombarded by multiple atrial impulses at rates often exceeding 350
to 600 per minute). The AV node blocks most of these impulses, allowing only a variable number through to the ventricles, creating the classic
irregularly irregular pattern. Atrial flutter presents with characteristic sawtooth flutter waves (F waves) at a rate of 250 to 350 per minute,
often with a fixed conduction ratio (e.g., 2:1 or 4:1). Second-degree AV block type I (Wenckebach) shows progressively lengthening PR intervals
until a QRS complex is dropped, but with a regular underlying atrial rhythm. PVCs are premature, wide, bizarre QRS complexes that are not
preceded by a P wave, but the underlying rhythm remains regular between PVCs.
11. A nurse in the emergency department is caring for a client with a suspected ST-elevation myocardial infarction (STEMI).
The client's 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. The nurse should recognize that this indicates
infarction in which area of the heart?
A. Anterior wall
B. Lateral wall
C. Inferior wall [CORRECT]
D. Posterior wall
Correct Answer: C
Rationale: ST-segment elevation in leads II, III, and aVF is the hallmark of an inferior wall myocardial infarction. These leads face the
inferior (diaphragmatic) surface of the left ventricle. Anterior wall MI is indicated by ST elevation in leads V1 through V4. Lateral wall MI
shows ST elevation in leads I, aVL, V5, and V6. Posterior wall MI is suggested by ST depression in leads V1 through V3 (reciprocal changes)
and is often confirmed with posterior leads (V7, V8, V9). Recognizing the location of infarction is critical because different MI locations have
distinct complications: inferior MI is associated with bradycardia and heart block (because the right coronary artery also supplies the SA and
AV nodes), anterior MI is associated with ventricular dysrhythmias and heart failure, and lateral MI may involve the circumflex artery
territory.
12. A nurse is caring for a client who is 12 hours post-MI and develops sudden onset of dyspnea, bilateral crackles, and a pink
frothy sputum. The client's oxygen saturation is 88% on room air. Which of the following interventions should the nurse
implement first?
Page 4 Detailed Answer Key Included
