ATI RN Medical-Surgical Proctored Exam
2019 Retake Correct questions and
answers
Section 1: Cardiovascular System (Questions 1–25)
1. A nurse is caring for a client who has heart failure and is prescribed furosemide. Which of
the following findings indicates a therapeutic response to the medication?
A. Heart rate 112/min
B. Urine output 1000 mL/24 hr
C. Weight loss of 2 kg (4.4 lb) in 24 hr
D. Blood pressure 88/52 mm Hg
Correct Answer: C. Weight loss of 2 kg (4.4 lb) in 24 hr
Rationale: Furosemide is a loop diuretic prescribed to reduce fluid overload in heart failure.
A weight loss of 1–2 kg per day indicates effective diuresis and fluid mobilization. Heart rate
112/min indicates tachycardia, which is not therapeutic. Urine output of 1000 mL/24 hr is below
the expected minimum of 1500 mL for an adult. Blood pressure 88/52 mm Hg indicates
hypotension, an adverse effect rather than a therapeutic response.
2. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the
following findings should the nurse report to the provider before administering the
medication?
A. Heart rate 58/min
B. Potassium 4.2 mEq/L
C. Blood pressure 128/76 mm Hg
D. Digoxin level 0.8 ng/mL
Correct Answer: A. Heart rate 58/min
Rationale: Digoxin slows the heart rate and is withheld if the adult heart rate is below
60/min. A heart rate of 58/min should be reported. Potassium 4.2 mEq/L is within the normal
range (3.5–5.0 mEq/L). Blood pressure 128/76 mm Hg is within normal limits. A digoxin level of
0.8 ng/mL is within the therapeutic range (0.5–2.0 ng/mL).
,3. A nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which
of the following client statements indicates an understanding of the teaching?
A. "I can take up to five tablets in 15 minutes before seeking medical attention."
B. "I should lie down when I take this medication."
C. "I should discontinue this medication if I develop a headache."
D. "I can keep my medications for 1 year before replacing them."
Correct Answer: B. "I should lie down when I take this medication."
Rationale: Sublingual nitroglycerin causes vasodilation, which can lead to hypotension and
dizziness. The client should lie down when taking the medication to prevent falls. The client
should take up to three tablets, not five, at 5-minute intervals before seeking emergency care.
Headache is a common expected side effect of nitroglycerin due to vasodilation and is not a
reason to discontinue the medication. Sublingual nitroglycerin should be replaced every 6
months, not 1 year, due to loss of potency.
4. A nurse is assessing a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
A. Administer an antihistamine
B. Slow the infusion rate
C. Give the client a corticosteroid
D. Elevate the client's lower extremities
Correct Answer: B. Slow the infusion rate
Rationale: Dyspnea, restlessness, and crackles during a blood transfusion indicate
circulatory overload. The nurse should slow or stop the infusion, place the client in an upright
position, and notify the provider. An antihistamine would be appropriate for an allergic reaction.
A corticosteroid would be appropriate for a hemolytic reaction. Elevating the lower extremities
is appropriate for hypovolemic shock, not fluid overload.
5. A nurse is caring for a client who has a new prescription for warfarin. Which of the
following laboratory values should the nurse monitor to evaluate the therapeutic effect of the
medication?
,A. aPTT
B. INR
C. Platelet count
D. Hemoglobin
Correct Answer: B. INR
Rationale: Warfarin is monitored using the INR (International Normalized Ratio), with a
therapeutic range of 2.0–3.0 for most indications. aPTT is used to monitor heparin therapy.
Platelet count assesses for thrombocytopenia, which is not the primary monitoring parameter
for warfarin. Hemoglobin assesses for anemia but does not evaluate warfarin's anticoagulant
effect.
6. A nurse is assessing a client who has peripheral arterial disease (PAD). Which of the
following findings should the nurse expect? (Select all that apply.)
A. Thick, yellow toenails
B. Bounding pedal pulses
C. Dependent rubor
D. Hair loss on the lower legs
E. Warm extremities
Correct Answers: A, C, D
Rationale: Peripheral arterial disease results from decreased arterial blood flow to the
extremities. Expected findings include thickened toenails (A), dependent rubor (C) due to
vasodilation when the leg is dependent, and hair loss on the lower legs (D) due to decreased
perfusion. Bounding pedal pulses and warm extremities are findings associated with venous
insufficiency, not arterial insufficiency.
7. A nurse is caring for a client following a cardiac catheterization. Which of the following
actions should the nurse take?
A. Keep the client on bed rest for 24 hours
B. Maintain the client's affected extremity in extension
C. Change the client's dressing every 8 hours
D. Limit the client's fluid intake to 1 L per day
Correct Answer: B. Maintain the client's affected extremity in extension
, Rationale: After cardiac catheterization, the affected extremity should be kept straight (in
extension) to prevent bleeding at the catheter insertion site. Bed rest is typically maintained for
2–6 hours, not 24 hours. The dressing is usually left intact for 24 hours unless bleeding occurs.
Fluid intake should be encouraged, not limited, to help flush the contrast dye from the kidneys.
8. A nurse is teaching a client who has hypertension about dietary modifications. Which of the
following foods should the nurse recommend the client limit?
A. Fresh apples
B. Baked chicken
C. Canned soup
D. Steamed broccoli
Correct Answer: C. Canned soup
Rationale: Canned soup is high in sodium, which can worsen hypertension. Clients should
limit high-sodium foods such as canned soups, processed meats, and frozen meals. Fresh
apples, baked chicken (without added salt), and steamed broccoli are low-sodium choices
appropriate for a hypertension diet.
9. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left leg. Which of
the following findings should the nurse expect?
A. Cool, pale skin on the affected leg
B. Unilateral edema of the left leg
C. Decreased pedal pulses bilaterally
D. Intermittent claudication
Correct Answer: B. Unilateral edema of the left leg
Rationale: DVT typically presents with unilateral edema, warmth, redness, and pain in the
affected extremity. Cool, pale skin and decreased pedal pulses are findings associated with
arterial insufficiency. Intermittent claudication is associated with peripheral arterial disease.
10. A nurse is caring for a client who is postoperative following a coronary artery bypass graft
(CABG). Which of the following findings should the nurse report immediately?
2019 Retake Correct questions and
answers
Section 1: Cardiovascular System (Questions 1–25)
1. A nurse is caring for a client who has heart failure and is prescribed furosemide. Which of
the following findings indicates a therapeutic response to the medication?
A. Heart rate 112/min
B. Urine output 1000 mL/24 hr
C. Weight loss of 2 kg (4.4 lb) in 24 hr
D. Blood pressure 88/52 mm Hg
Correct Answer: C. Weight loss of 2 kg (4.4 lb) in 24 hr
Rationale: Furosemide is a loop diuretic prescribed to reduce fluid overload in heart failure.
A weight loss of 1–2 kg per day indicates effective diuresis and fluid mobilization. Heart rate
112/min indicates tachycardia, which is not therapeutic. Urine output of 1000 mL/24 hr is below
the expected minimum of 1500 mL for an adult. Blood pressure 88/52 mm Hg indicates
hypotension, an adverse effect rather than a therapeutic response.
2. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the
following findings should the nurse report to the provider before administering the
medication?
A. Heart rate 58/min
B. Potassium 4.2 mEq/L
C. Blood pressure 128/76 mm Hg
D. Digoxin level 0.8 ng/mL
Correct Answer: A. Heart rate 58/min
Rationale: Digoxin slows the heart rate and is withheld if the adult heart rate is below
60/min. A heart rate of 58/min should be reported. Potassium 4.2 mEq/L is within the normal
range (3.5–5.0 mEq/L). Blood pressure 128/76 mm Hg is within normal limits. A digoxin level of
0.8 ng/mL is within the therapeutic range (0.5–2.0 ng/mL).
,3. A nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which
of the following client statements indicates an understanding of the teaching?
A. "I can take up to five tablets in 15 minutes before seeking medical attention."
B. "I should lie down when I take this medication."
C. "I should discontinue this medication if I develop a headache."
D. "I can keep my medications for 1 year before replacing them."
Correct Answer: B. "I should lie down when I take this medication."
Rationale: Sublingual nitroglycerin causes vasodilation, which can lead to hypotension and
dizziness. The client should lie down when taking the medication to prevent falls. The client
should take up to three tablets, not five, at 5-minute intervals before seeking emergency care.
Headache is a common expected side effect of nitroglycerin due to vasodilation and is not a
reason to discontinue the medication. Sublingual nitroglycerin should be replaced every 6
months, not 1 year, due to loss of potency.
4. A nurse is assessing a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions
should the nurse anticipate taking?
A. Administer an antihistamine
B. Slow the infusion rate
C. Give the client a corticosteroid
D. Elevate the client's lower extremities
Correct Answer: B. Slow the infusion rate
Rationale: Dyspnea, restlessness, and crackles during a blood transfusion indicate
circulatory overload. The nurse should slow or stop the infusion, place the client in an upright
position, and notify the provider. An antihistamine would be appropriate for an allergic reaction.
A corticosteroid would be appropriate for a hemolytic reaction. Elevating the lower extremities
is appropriate for hypovolemic shock, not fluid overload.
5. A nurse is caring for a client who has a new prescription for warfarin. Which of the
following laboratory values should the nurse monitor to evaluate the therapeutic effect of the
medication?
,A. aPTT
B. INR
C. Platelet count
D. Hemoglobin
Correct Answer: B. INR
Rationale: Warfarin is monitored using the INR (International Normalized Ratio), with a
therapeutic range of 2.0–3.0 for most indications. aPTT is used to monitor heparin therapy.
Platelet count assesses for thrombocytopenia, which is not the primary monitoring parameter
for warfarin. Hemoglobin assesses for anemia but does not evaluate warfarin's anticoagulant
effect.
6. A nurse is assessing a client who has peripheral arterial disease (PAD). Which of the
following findings should the nurse expect? (Select all that apply.)
A. Thick, yellow toenails
B. Bounding pedal pulses
C. Dependent rubor
D. Hair loss on the lower legs
E. Warm extremities
Correct Answers: A, C, D
Rationale: Peripheral arterial disease results from decreased arterial blood flow to the
extremities. Expected findings include thickened toenails (A), dependent rubor (C) due to
vasodilation when the leg is dependent, and hair loss on the lower legs (D) due to decreased
perfusion. Bounding pedal pulses and warm extremities are findings associated with venous
insufficiency, not arterial insufficiency.
7. A nurse is caring for a client following a cardiac catheterization. Which of the following
actions should the nurse take?
A. Keep the client on bed rest for 24 hours
B. Maintain the client's affected extremity in extension
C. Change the client's dressing every 8 hours
D. Limit the client's fluid intake to 1 L per day
Correct Answer: B. Maintain the client's affected extremity in extension
, Rationale: After cardiac catheterization, the affected extremity should be kept straight (in
extension) to prevent bleeding at the catheter insertion site. Bed rest is typically maintained for
2–6 hours, not 24 hours. The dressing is usually left intact for 24 hours unless bleeding occurs.
Fluid intake should be encouraged, not limited, to help flush the contrast dye from the kidneys.
8. A nurse is teaching a client who has hypertension about dietary modifications. Which of the
following foods should the nurse recommend the client limit?
A. Fresh apples
B. Baked chicken
C. Canned soup
D. Steamed broccoli
Correct Answer: C. Canned soup
Rationale: Canned soup is high in sodium, which can worsen hypertension. Clients should
limit high-sodium foods such as canned soups, processed meats, and frozen meals. Fresh
apples, baked chicken (without added salt), and steamed broccoli are low-sodium choices
appropriate for a hypertension diet.
9. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left leg. Which of
the following findings should the nurse expect?
A. Cool, pale skin on the affected leg
B. Unilateral edema of the left leg
C. Decreased pedal pulses bilaterally
D. Intermittent claudication
Correct Answer: B. Unilateral edema of the left leg
Rationale: DVT typically presents with unilateral edema, warmth, redness, and pain in the
affected extremity. Cool, pale skin and decreased pedal pulses are findings associated with
arterial insufficiency. Intermittent claudication is associated with peripheral arterial disease.
10. A nurse is caring for a client who is postoperative following a coronary artery bypass graft
(CABG). Which of the following findings should the nurse report immediately?
