ATI RN Adult Medical-
Surgical ATI RN Adult
Medical-Surgical
Cardiovascular System
1. A nurse is assessing a client who has heart failure and is taking furosemide. Which of the
following findings should the nurse identify as an adverse effect of this medication?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Bradycardia
Correct Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading to hypokalemia.
Clients should be monitored for low potassium levels and may need potassium supplementation
or a potassium-rich diet. Hyperkalemia is associated with potassium-sparing diuretics.
Hypernatremia and bradycardia are not typical adverse effects of furosemide.
2. A nurse is caring for a client who has atrial fibrillation and a heart rate of 138/min. Which of
the following medications should the nurse anticipate administering to control the heart rate?
A. Atropine
B. Diltiazem
C. Adenosine
D. Epinephrine
Correct Answer: B. Diltiazem
, Rationale: Diltiazem, a calcium channel blocker, is used to control heart rate in clients with
atrial fibrillation by slowing conduction through the AV node. Atropine is used for bradycardia.
Adenosine is used for supraventricular tachycardia. Epinephrine is used for cardiac arrest and
anaphylaxis.
3. A nurse is teaching a client who has hypertension about lifestyle modifications. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I should limit my sodium intake to 4,000 mg per day."
B. "I should engage in aerobic exercise for at least 150 minutes per week."
C. "I should drink at least 3 alcoholic beverages per day."
D. "I should avoid all physical activity to prevent stress on my heart."
Correct Answer: B. "I should engage in aerobic exercise for at least 150 minutes per
week."
Rationale: The American Heart Association recommends at least 150 minutes of moderate-
intensity aerobic exercise per week for clients with hypertension. Sodium intake should be
limited to less than 1,500–2,300 mg per day. Alcohol should be limited. Physical activity is
encouraged, not avoided.
4. A nurse is assessing a client who has peripheral arterial disease (PAD). Which of the
following findings should the nurse expect?
A. Dependent rubor
B. Pitting edema
C. Warm, red extremities
D. Strong pedal pulses
Correct Answer: A. Dependent rubor
Rationale: Dependent rubor is a classic sign of PAD, where the affected extremity becomes
red when dependent due to vasodilation. Pitting edema, warm red extremities, and strong
pedal pulses are associated with venous insufficiency, not PAD. PAD typically presents with cool,
pale extremities and diminished pulses.
5. A nurse is caring for a client who is receiving heparin therapy. Which of the following
laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
,A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Correct Answer: C. Activated partial thromboplastin time (aPTT)
Rationale: aPTT is used to monitor the effectiveness of heparin therapy. The therapeutic
range is typically 1.5–2.5 times the control value. PT and INR are used to monitor warfarin
therapy. Platelet count is monitored for heparin-induced thrombocytopenia, but not for
therapeutic effectiveness.
6. 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. Warmth and redness in the affected leg
B. Pallor and coolness in the affected leg
C. Diminished pedal pulses
D. Ulceration around the ankle
Correct Answer: A. Warmth and redness in the affected leg
Rationale: DVT presents with warmth, redness, swelling, and pain in the affected extremity.
Pallor, coolness, and diminished pulses are signs of arterial insufficiency. Ulceration around the
ankle is typically associated with venous insufficiency.
7. A nurse is caring for a client who is taking warfarin. The client's INR is 5.5. Which of the
following actions should the nurse take?
A. Administer vitamin K
B. Increase the warfarin dose
C. Administer heparin
D. Continue the current dose
Correct Answer: A. Administer vitamin K
Rationale: An INR of 5.5 is above the therapeutic range (2–3 for most clients), indicating an
increased risk of bleeding. Vitamin K is the antidote for warfarin overdose. Increasing the dose
would worsen the situation. Heparin does not reverse warfarin. Continuing the current dose
would not address the elevated INR.
, 8. A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea. Right-sided heart failure leads to systemic congestion, causing jugular
vein distention, peripheral edema, and hepatomegaly.
9. A nurse is teaching a client who has been prescribed nitroglycerin for angina. Which of the
following instructions should the nurse include?
A. "Take the medication with food."
B. "Store the medication in a cool, dark place."
C. "Take the medication only when you have chest pain."
D. "Swallow the tablet whole with water."
Correct Answer: B. "Store the medication in a cool, dark place."
Rationale: Nitroglycerin should be stored in a cool, dark place in its original container to
maintain potency. It is taken sublingually, not with food or swallowed whole. It can be taken
prophylactically before activities that may precipitate angina.
10. A nurse is caring for a client who has just undergone a cardiac catheterization. Which of
the following findings should the nurse report immediately?
A. Minor bruising at the insertion site
B. Blood pressure of 110/70 mm Hg
C. Bleeding at the insertion site
D. Heart rate of 78/min
Correct Answer: C. Bleeding at the insertion site
Surgical ATI RN Adult
Medical-Surgical
Cardiovascular System
1. A nurse is assessing a client who has heart failure and is taking furosemide. Which of the
following findings should the nurse identify as an adverse effect of this medication?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Bradycardia
Correct Answer: B. Hypokalemia
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading to hypokalemia.
Clients should be monitored for low potassium levels and may need potassium supplementation
or a potassium-rich diet. Hyperkalemia is associated with potassium-sparing diuretics.
Hypernatremia and bradycardia are not typical adverse effects of furosemide.
2. A nurse is caring for a client who has atrial fibrillation and a heart rate of 138/min. Which of
the following medications should the nurse anticipate administering to control the heart rate?
A. Atropine
B. Diltiazem
C. Adenosine
D. Epinephrine
Correct Answer: B. Diltiazem
, Rationale: Diltiazem, a calcium channel blocker, is used to control heart rate in clients with
atrial fibrillation by slowing conduction through the AV node. Atropine is used for bradycardia.
Adenosine is used for supraventricular tachycardia. Epinephrine is used for cardiac arrest and
anaphylaxis.
3. A nurse is teaching a client who has hypertension about lifestyle modifications. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I should limit my sodium intake to 4,000 mg per day."
B. "I should engage in aerobic exercise for at least 150 minutes per week."
C. "I should drink at least 3 alcoholic beverages per day."
D. "I should avoid all physical activity to prevent stress on my heart."
Correct Answer: B. "I should engage in aerobic exercise for at least 150 minutes per
week."
Rationale: The American Heart Association recommends at least 150 minutes of moderate-
intensity aerobic exercise per week for clients with hypertension. Sodium intake should be
limited to less than 1,500–2,300 mg per day. Alcohol should be limited. Physical activity is
encouraged, not avoided.
4. A nurse is assessing a client who has peripheral arterial disease (PAD). Which of the
following findings should the nurse expect?
A. Dependent rubor
B. Pitting edema
C. Warm, red extremities
D. Strong pedal pulses
Correct Answer: A. Dependent rubor
Rationale: Dependent rubor is a classic sign of PAD, where the affected extremity becomes
red when dependent due to vasodilation. Pitting edema, warm red extremities, and strong
pedal pulses are associated with venous insufficiency, not PAD. PAD typically presents with cool,
pale extremities and diminished pulses.
5. A nurse is caring for a client who is receiving heparin therapy. Which of the following
laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
,A. Prothrombin time (PT)
B. International normalized ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
Correct Answer: C. Activated partial thromboplastin time (aPTT)
Rationale: aPTT is used to monitor the effectiveness of heparin therapy. The therapeutic
range is typically 1.5–2.5 times the control value. PT and INR are used to monitor warfarin
therapy. Platelet count is monitored for heparin-induced thrombocytopenia, but not for
therapeutic effectiveness.
6. 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. Warmth and redness in the affected leg
B. Pallor and coolness in the affected leg
C. Diminished pedal pulses
D. Ulceration around the ankle
Correct Answer: A. Warmth and redness in the affected leg
Rationale: DVT presents with warmth, redness, swelling, and pain in the affected extremity.
Pallor, coolness, and diminished pulses are signs of arterial insufficiency. Ulceration around the
ankle is typically associated with venous insufficiency.
7. A nurse is caring for a client who is taking warfarin. The client's INR is 5.5. Which of the
following actions should the nurse take?
A. Administer vitamin K
B. Increase the warfarin dose
C. Administer heparin
D. Continue the current dose
Correct Answer: A. Administer vitamin K
Rationale: An INR of 5.5 is above the therapeutic range (2–3 for most clients), indicating an
increased risk of bleeding. Vitamin K is the antidote for warfarin overdose. Increasing the dose
would worsen the situation. Heparin does not reverse warfarin. Continuing the current dose
would not address the elevated INR.
, 8. A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect?
A. Jugular vein distention
B. Peripheral edema
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion, resulting in crackles,
dyspnea, and orthopnea. Right-sided heart failure leads to systemic congestion, causing jugular
vein distention, peripheral edema, and hepatomegaly.
9. A nurse is teaching a client who has been prescribed nitroglycerin for angina. Which of the
following instructions should the nurse include?
A. "Take the medication with food."
B. "Store the medication in a cool, dark place."
C. "Take the medication only when you have chest pain."
D. "Swallow the tablet whole with water."
Correct Answer: B. "Store the medication in a cool, dark place."
Rationale: Nitroglycerin should be stored in a cool, dark place in its original container to
maintain potency. It is taken sublingually, not with food or swallowed whole. It can be taken
prophylactically before activities that may precipitate angina.
10. A nurse is caring for a client who has just undergone a cardiac catheterization. Which of
the following findings should the nurse report immediately?
A. Minor bruising at the insertion site
B. Blood pressure of 110/70 mm Hg
C. Bleeding at the insertion site
D. Heart rate of 78/min
Correct Answer: C. Bleeding at the insertion site
