ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
ATI Medical-Surgical Nursing Proctored Exam 2026/2027 -
Form B
Comprehensive Practice Assessment with ATI-Focused Clinical Rationales
Aligned with ATI Test Plan Competencies | 90 Single-Best-Answer Items
Total Questions 90 (single best answer)
Cognitive Level Recall 30% | Application 50% | Analysis 20%
Question Format 80% scenario-based | 20% direct recall
Time Allotment 180 minutes (2 minutes/question)
Passing Standard Proficiency Level 2 or higher
Section 1: Cardiovascular and Hematologic Systems (Q1-Q15)
CAD, MI, Heart Failure, Dysrhythmias, Hypertension, Anemias, and Coagulopathies
Q1: A 58-year-old male client presents to the emergency department with substernal chest pain rated 8/10,
diaphoresis, and nausea that began 45 minutes ago while shoveling snow. The 12-lead ECG shows
ST-segment elevation in leads II, III, and aVF. Which action should the nurse take FIRST?
A. Administer sublingual nitroglycerin 0.4 mg and reassess pain in 5 minutes
B. Establish two large-bore IV catheters and prepare for MONA-B therapy
C. Assess vital signs, oxygen saturation, and obtain a brief health history
D. Administer 325 mg chewable aspirin and notify the cardiac catheterization team [CORRECT]
Correct Answer: D
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall ST-elevation myocardial infarction
(STEMI). The priority intervention is to chew 325 mg aspirin to inhibit platelet aggregation and immediately activate
the cardiac catheterization team for percutaneous coronary intervention (PCI), the gold-standard reperfusion therapy
within 90 minutes of first medical contact (door-to-balloon time). Nitroglycerin is held until right ventricular
involvement is ruled out (a 12-lead ECG with right-sided V4R), as inferior wall MIs frequently involve the right
ventricle and nitroglycerin can precipitate life-threatening hypotension. Aspirin administration is the single most
cost-effective early intervention and takes priority over IV access or reassessment. ATI testing strategy: apply the
ABCs and acute coronary syndrome (ACS) protocol; definitive reperfusion trumps symptomatic management.
Q2: A nurse is caring for a client with acute decompensated heart failure receiving IV furosemide 40 mg IV
push twice daily. The morning potassium level is 3.1 mEq/L. Which finding requires IMMEDIATE
intervention by the nurse?
A. The client reports waking twice during the night to urinate
B. The client has a 2-pound weight loss since yesterday
C. The client reports muscle weakness and cramping in the legs
D. The client has a heart rate of 88 bpm with occasional PVCs on telemetry [CORRECT]
Correct Answer: D
Nursing Education | Form B Page 1
,ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Rationale: A potassium level of 3.1 mEq/L (normal 3.5-5.0 mEq/L) is moderate hypokalemia, but the presence of
premature ventricular contractions (PVCs) on telemetry indicates the hypokalemia has destabilized myocardial
conduction and is progressing toward life-threatening dysrhythmias such as torsades de pointes or ventricular
tachycardia. ATI prioritization: actual or potential cardiac dysrhythmias are always immediately life-threatening
(ABC-Circulation). Muscle weakness and leg cramping are expected symptoms of hypokalemia and warrant reporting,
but the dysrhythmia is the immediate concern. Increased nocturia and weight loss are therapeutic responses to
furosemide indicating effective fluid removal. Test-taking strategy: in heart failure on loop diuretics, always assess
cardiac rhythm when potassium is below 3.5 mEq/L; a dysrhythmia is a "never-event" requiring prompt potassium
replacement and possible telemetry monitoring escalation.
Q3: A client with new-onset atrial fibrillation has a heart rate of 142 bpm and blood pressure of 96/62 mm
Hg. The provider orders diltiazem 20 mg IV push. Which assessment finding should the nurse report to the
provider BEFORE administering the medication?
A. The client has a widened QRS complex of 0.14 seconds on the ECG
B. The client received a dose of metoprolol 5 mg IV 30 minutes ago [CORRECT]
C. The client has a history of stage 1 hypertension treated with lisinopril
D. The client has an apical-radial pulse deficit of 18 beats per minute
Correct Answer: B
Rationale: Diltiazem is a non-dihydropyridine calcium channel blocker that slows AV node conduction and reduces
heart rate. Administering diltiazem within 30-60 minutes of an IV beta-blocker like metoprolol creates additive
negative chronotropic and dromotropic effects, significantly increasing the risk of severe bradycardia, heart block, or
hemodynamic collapse. This combination requires the provider to choose one agent class only or stagger
administration by at least 4 hours. The apical-radial pulse deficit (option D) is an expected finding in atrial fibrillation
and does not contraindicate diltiazem. Stage 1 hypertension history (option C) is not relevant to the immediate acute
rate-control decision. A widened QRS (option A) of 0.14 seconds suggests ventricular conduction delay; while it
warrants investigation, the recent IV metoprolol is the immediate safety concern. ATI strategy: assess recent
medication administration before giving any rate-control agent; suspect additive effects when multiple agents share
the same pharmacodynamic target (AV node).
Q4: A 67-year-old client is admitted with a hypertensive emergency (BP 220/128 mm Hg) and is receiving
IV nitroprusside. The client now reports dizziness, and the blood pressure is 96/58 mm Hg. Which action
should the nurse take FIRST?
A. Increase the IV nitroprusside rate to maintain tight BP control
B. Discontinue the nitroprusside infusion and notify the rapid response team [CORRECT]
C. Administer a 500 mL IV fluid bolus of 0.9% normal saline
D. Assess the client's level of consciousness and pupils
Correct Answer: B
Rationale: Nitroprusside is a potent ultrashort-acting arterial and venous vasodilator titrated for tight BP control in
hypertensive emergency. The first sign of overshoot hypotension is dizziness; the first nursing action is to STOP the
infusion, because the drug has a half-life of less than 2 minutes and the BP will rapidly rebound once the infusion is
off. Increasing the rate (option A) would worsen the hypotension. Fluid bolus (option C) may be needed after stopping
the drug, but stopping the offending agent is the priority. Assessment (option D) is appropriate but secondary to
removing the cause. ATI testing strategy: when an IV titratable vasoactive medication causes an adverse effect, the
FIRST action is always to stop or reduce the infusion, then reassess and notify. The "Stop the drip first" principle is a
recurring ATI pattern for vasoactive medications including nitroprusside, nitroglycerin, Nipride, and vasoactive drips
like norepinephrine.
Nursing Education | Form B Page 2
,ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Q5: A nurse is teaching a client with heart failure about the daily use of lisinopril 10 mg. Which statement
by the client indicates the teaching has been EFFECTIVE?
A. "I should take this medication with a grapefruit juice to improve absorption."
B. "I will call my provider if I develop a dry hacking cough that does not go away." [CORRECT]
C. "I should take an extra dose if I notice swelling in my ankles at the end of the day."
D. "I need to limit my potassium intake by avoiding bananas, oranges, and potatoes."
Correct Answer: B
Rationale: Lisinopril is an ACE inhibitor that may cause a persistent dry cough in up to 20% of clients due to
bradykinin accumulation in the lungs. While not life-threatening, the cough is the most common reason for medication
discontinuation and switch to an ARB (angiotensin receptor blocker). The client correctly recognizes this expected
adverse effect and the need to report it. Grapefruit juice interacts with CYP3A4 substrates like statins and calcium
channel blockers, not ACE inhibitors. Doubling the dose is unsafe and indicates misunderstanding of the medication
regimen. ACE inhibitors are potassium-sparing (inhibit aldosterone), so clients should be advised to AVOID salt
substitutes (which are potassium chloride) and avoid excessive potassium intake, not restrict all dietary potassium. ATI
strategy: patient teaching questions are answered correctly when the client identifies the most common/significant
adverse effect, the warning signs requiring provider notification, and appropriate self-management without
self-adjustment.
Q6: A client is admitted 24 hours ago for an acute ST-elevation myocardial infarction (STEMI) and
underwent primary PCI with stent placement. The client is receiving dual antiplatelet therapy (DAPT) with
aspirin and ticagrelor. Which assessment finding should the nurse report to the provider
IMMEDIATELY?
A. Black, tarry stools reported by the client on the second hospital day [CORRECT]
B. A 1 cm ecchymosis at the right femoral catheterization access site
C. Mild nausea and heartburn after taking the morning aspirin dose
D. A heart rate of 56 bpm with a blood pressure of 116/72 mm Hg
Correct Answer: A
Rationale: Black, tarry stools (melena) indicate upper gastrointestinal bleeding, a life-threatening complication of
dual antiplatelet therapy that requires immediate provider notification, holding of antiplatelet agents,
hemoglobin/hematocrit assessment, possible endoscopy, and potentially platelet transfusion or reversal agents. The
femoral access site ecchymosis (option B) is a common minor bleeding complication that warrants monitoring but is
not emergent. Nausea and heartburn with aspirin (option C) are expected and managed with enteric-coated
formulations or PPIs. A heart rate of 56 bpm (option D) in a client on beta-blockers post-MI is acceptable if
asymptomatic and systolic BP > 90 mm Hg. ATI strategy: post-PCI clients on DAPT have a quantifiable bleeding risk;
any sign of internal bleeding (melena, hematemesis, hematuria, altered mental status with drop in H/H, hypotension) is
a "red flag" requiring immediate escalation. The pattern: GI bleeding signs in clients on anticoagulants/antiplatelets =
highest priority.
Q7: A 72-year-old client with chronic atrial fibrillation is receiving warfarin 5 mg daily. The INR today is
4.8 (therapeutic range 2.0-3.0 for atrial fibrillation). The client denies bleeding. Which provider order
should the nurse anticipate?
A. Administer 10 mg vitamin K IV push immediately
B. Hold the next warfarin dose and recheck INR in 24 hours [CORRECT]
C. Administer 4 units of fresh frozen plasma over 30 minutes
D. Continue warfarin at the same dose and recheck INR in 7 days
Correct Answer: B
Nursing Education | Form B Page 3
, ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Rationale: Per the American College of Chest Physicians (CHEST) guidelines, an INR between 4.5 and 10 without
bleeding requires holding the next dose(s) of warfarin and monitoring closely, with optional low-dose oral vitamin K
(1-2.5 mg). IV push vitamin K (option A) is reserved for serious or life-threatening bleeding with markedly elevated
INR (>10) due to rapid reversal but risk of anaphylaxis and "warfarin resistance" for weeks. Fresh frozen plasma
(option C) is indicated only for active bleeding with elevated INR. Continuing the same dose (option D) would worsen
the supratherapeutic state. ATI strategy: do not "over-treat" asymptomatic INR elevations; minimal intervention is the
standard. The nurse anticipates the most conservative guideline-based action: hold and recheck. Test-taking: when
"without bleeding" appears in the stem, the answer is almost always "hold and monitor," not "administer antidote."
Q8: A 24-year-old female client reports profound fatigue, pallor, and brittle nails for the past 3 months.
Her hemoglobin is 8.6 g/dL, MCV 72 fL, and serum ferritin 8 ng/mL. She reports heavy menstrual periods
(lasting 7-9 days). Which intervention is MOST appropriate for the nurse to include in the plan of care?
A. Administer a 1-unit packed red blood cell transfusion over 4 hours
B. Teach the client to take oral ferrous sulfate 325 mg with orange juice on an empty stomach
[CORRECT]
C. Instruct the client to consume iron-rich foods only and recheck the CBC in 6 months
D. Recommend an iron dextran IV infusion weekly for 8 weeks
Correct Answer: B
Rationale: The client has classic iron-deficiency anemia (low Hgb, microcytic MCV <80, low ferritin <15) caused by
heavy menstrual blood loss. The first-line treatment for stable iron-deficiency anemia is oral ferrous sulfate 325 mg
once to three times daily, taken on an empty stomach with vitamin C (ascorbic acid, e.g., orange juice) to enhance
absorption. Blood transfusion (option A) is reserved for hemodynamically unstable clients or Hgb below 7 g/dL with
symptoms of tissue hypoxia. Diet alone (option C) is insufficient to replete iron stores in the setting of ongoing blood
loss. IV iron (option D) is reserved for clients with malabsorption, severe intolerance to oral iron, or chronic kidney
disease. ATI strategy: stable iron-deficiency anemia in a menstruating female is treated with oral ferrous sulfate +
vitamin C; teach clients that black stools are expected and to continue therapy for 3-6 months after hemoglobin
normalizes to replete iron stores.
Q9: A 16-year-old African American male client presents to the emergency department with severe pain in
the lower back and both knees, rating the pain 9/10. He has a history of sickle cell disease. Vital signs: T
38.4°C (101.1°F), HR 124, BP 104/64, RR 26, SpO2 92% on room air. Which provider order should the
nurse implement FIRST?
A. Administer morphine 4 mg IV push now and every 3 hours PRN for pain
B. Start IV 0.9% normal saline at 250 mL/hr and apply warm moist packs to painful joints
C. Obtain blood, urine, and sputum cultures and administer ceftriaxone IV
D. Administer 2 units of oxygen via nasal cannula and titrate to keep SpO2 ≥ 95% [CORRECT]
Correct Answer: D
Rationale: The client is in an acute vaso-occlusive sickle cell crisis with hypoxia (SpO2 92%). Hypoxia is the most
common trigger of sickling; therefore the PRIORITY is supplemental oxygen to maintain SpO2 at or above 95%,
which reduces sickling and improves tissue oxygenation. All other interventions (IV fluids, pain control, antibiotics)
are essential and concurrent, but oxygen addresses the ABCs (Airway/Breathing first) and the underlying
pathophysiology. Pain control (option A) and IV fluids (option B) follow closely, but in ATI prioritization, when ABC
compromise exists, that intervention takes precedence. Antibiotics (option C) are appropriate given the fever, which is
concerning for infection-triggered crisis, but stabilizing oxygenation comes first. ATI strategy: acute prioritization
uses the ABC framework; hypoxia is always addressed first. Pain, while severe, is treated after stabilization of
oxygenation in crisis.
Nursing Education | Form B Page 4
ATI Medical-Surgical Nursing Proctored Exam 2026/2027 -
Form B
Comprehensive Practice Assessment with ATI-Focused Clinical Rationales
Aligned with ATI Test Plan Competencies | 90 Single-Best-Answer Items
Total Questions 90 (single best answer)
Cognitive Level Recall 30% | Application 50% | Analysis 20%
Question Format 80% scenario-based | 20% direct recall
Time Allotment 180 minutes (2 minutes/question)
Passing Standard Proficiency Level 2 or higher
Section 1: Cardiovascular and Hematologic Systems (Q1-Q15)
CAD, MI, Heart Failure, Dysrhythmias, Hypertension, Anemias, and Coagulopathies
Q1: A 58-year-old male client presents to the emergency department with substernal chest pain rated 8/10,
diaphoresis, and nausea that began 45 minutes ago while shoveling snow. The 12-lead ECG shows
ST-segment elevation in leads II, III, and aVF. Which action should the nurse take FIRST?
A. Administer sublingual nitroglycerin 0.4 mg and reassess pain in 5 minutes
B. Establish two large-bore IV catheters and prepare for MONA-B therapy
C. Assess vital signs, oxygen saturation, and obtain a brief health history
D. Administer 325 mg chewable aspirin and notify the cardiac catheterization team [CORRECT]
Correct Answer: D
Rationale: ST-segment elevation in leads II, III, and aVF indicates an inferior wall ST-elevation myocardial infarction
(STEMI). The priority intervention is to chew 325 mg aspirin to inhibit platelet aggregation and immediately activate
the cardiac catheterization team for percutaneous coronary intervention (PCI), the gold-standard reperfusion therapy
within 90 minutes of first medical contact (door-to-balloon time). Nitroglycerin is held until right ventricular
involvement is ruled out (a 12-lead ECG with right-sided V4R), as inferior wall MIs frequently involve the right
ventricle and nitroglycerin can precipitate life-threatening hypotension. Aspirin administration is the single most
cost-effective early intervention and takes priority over IV access or reassessment. ATI testing strategy: apply the
ABCs and acute coronary syndrome (ACS) protocol; definitive reperfusion trumps symptomatic management.
Q2: A nurse is caring for a client with acute decompensated heart failure receiving IV furosemide 40 mg IV
push twice daily. The morning potassium level is 3.1 mEq/L. Which finding requires IMMEDIATE
intervention by the nurse?
A. The client reports waking twice during the night to urinate
B. The client has a 2-pound weight loss since yesterday
C. The client reports muscle weakness and cramping in the legs
D. The client has a heart rate of 88 bpm with occasional PVCs on telemetry [CORRECT]
Correct Answer: D
Nursing Education | Form B Page 1
,ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Rationale: A potassium level of 3.1 mEq/L (normal 3.5-5.0 mEq/L) is moderate hypokalemia, but the presence of
premature ventricular contractions (PVCs) on telemetry indicates the hypokalemia has destabilized myocardial
conduction and is progressing toward life-threatening dysrhythmias such as torsades de pointes or ventricular
tachycardia. ATI prioritization: actual or potential cardiac dysrhythmias are always immediately life-threatening
(ABC-Circulation). Muscle weakness and leg cramping are expected symptoms of hypokalemia and warrant reporting,
but the dysrhythmia is the immediate concern. Increased nocturia and weight loss are therapeutic responses to
furosemide indicating effective fluid removal. Test-taking strategy: in heart failure on loop diuretics, always assess
cardiac rhythm when potassium is below 3.5 mEq/L; a dysrhythmia is a "never-event" requiring prompt potassium
replacement and possible telemetry monitoring escalation.
Q3: A client with new-onset atrial fibrillation has a heart rate of 142 bpm and blood pressure of 96/62 mm
Hg. The provider orders diltiazem 20 mg IV push. Which assessment finding should the nurse report to the
provider BEFORE administering the medication?
A. The client has a widened QRS complex of 0.14 seconds on the ECG
B. The client received a dose of metoprolol 5 mg IV 30 minutes ago [CORRECT]
C. The client has a history of stage 1 hypertension treated with lisinopril
D. The client has an apical-radial pulse deficit of 18 beats per minute
Correct Answer: B
Rationale: Diltiazem is a non-dihydropyridine calcium channel blocker that slows AV node conduction and reduces
heart rate. Administering diltiazem within 30-60 minutes of an IV beta-blocker like metoprolol creates additive
negative chronotropic and dromotropic effects, significantly increasing the risk of severe bradycardia, heart block, or
hemodynamic collapse. This combination requires the provider to choose one agent class only or stagger
administration by at least 4 hours. The apical-radial pulse deficit (option D) is an expected finding in atrial fibrillation
and does not contraindicate diltiazem. Stage 1 hypertension history (option C) is not relevant to the immediate acute
rate-control decision. A widened QRS (option A) of 0.14 seconds suggests ventricular conduction delay; while it
warrants investigation, the recent IV metoprolol is the immediate safety concern. ATI strategy: assess recent
medication administration before giving any rate-control agent; suspect additive effects when multiple agents share
the same pharmacodynamic target (AV node).
Q4: A 67-year-old client is admitted with a hypertensive emergency (BP 220/128 mm Hg) and is receiving
IV nitroprusside. The client now reports dizziness, and the blood pressure is 96/58 mm Hg. Which action
should the nurse take FIRST?
A. Increase the IV nitroprusside rate to maintain tight BP control
B. Discontinue the nitroprusside infusion and notify the rapid response team [CORRECT]
C. Administer a 500 mL IV fluid bolus of 0.9% normal saline
D. Assess the client's level of consciousness and pupils
Correct Answer: B
Rationale: Nitroprusside is a potent ultrashort-acting arterial and venous vasodilator titrated for tight BP control in
hypertensive emergency. The first sign of overshoot hypotension is dizziness; the first nursing action is to STOP the
infusion, because the drug has a half-life of less than 2 minutes and the BP will rapidly rebound once the infusion is
off. Increasing the rate (option A) would worsen the hypotension. Fluid bolus (option C) may be needed after stopping
the drug, but stopping the offending agent is the priority. Assessment (option D) is appropriate but secondary to
removing the cause. ATI testing strategy: when an IV titratable vasoactive medication causes an adverse effect, the
FIRST action is always to stop or reduce the infusion, then reassess and notify. The "Stop the drip first" principle is a
recurring ATI pattern for vasoactive medications including nitroprusside, nitroglycerin, Nipride, and vasoactive drips
like norepinephrine.
Nursing Education | Form B Page 2
,ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Q5: A nurse is teaching a client with heart failure about the daily use of lisinopril 10 mg. Which statement
by the client indicates the teaching has been EFFECTIVE?
A. "I should take this medication with a grapefruit juice to improve absorption."
B. "I will call my provider if I develop a dry hacking cough that does not go away." [CORRECT]
C. "I should take an extra dose if I notice swelling in my ankles at the end of the day."
D. "I need to limit my potassium intake by avoiding bananas, oranges, and potatoes."
Correct Answer: B
Rationale: Lisinopril is an ACE inhibitor that may cause a persistent dry cough in up to 20% of clients due to
bradykinin accumulation in the lungs. While not life-threatening, the cough is the most common reason for medication
discontinuation and switch to an ARB (angiotensin receptor blocker). The client correctly recognizes this expected
adverse effect and the need to report it. Grapefruit juice interacts with CYP3A4 substrates like statins and calcium
channel blockers, not ACE inhibitors. Doubling the dose is unsafe and indicates misunderstanding of the medication
regimen. ACE inhibitors are potassium-sparing (inhibit aldosterone), so clients should be advised to AVOID salt
substitutes (which are potassium chloride) and avoid excessive potassium intake, not restrict all dietary potassium. ATI
strategy: patient teaching questions are answered correctly when the client identifies the most common/significant
adverse effect, the warning signs requiring provider notification, and appropriate self-management without
self-adjustment.
Q6: A client is admitted 24 hours ago for an acute ST-elevation myocardial infarction (STEMI) and
underwent primary PCI with stent placement. The client is receiving dual antiplatelet therapy (DAPT) with
aspirin and ticagrelor. Which assessment finding should the nurse report to the provider
IMMEDIATELY?
A. Black, tarry stools reported by the client on the second hospital day [CORRECT]
B. A 1 cm ecchymosis at the right femoral catheterization access site
C. Mild nausea and heartburn after taking the morning aspirin dose
D. A heart rate of 56 bpm with a blood pressure of 116/72 mm Hg
Correct Answer: A
Rationale: Black, tarry stools (melena) indicate upper gastrointestinal bleeding, a life-threatening complication of
dual antiplatelet therapy that requires immediate provider notification, holding of antiplatelet agents,
hemoglobin/hematocrit assessment, possible endoscopy, and potentially platelet transfusion or reversal agents. The
femoral access site ecchymosis (option B) is a common minor bleeding complication that warrants monitoring but is
not emergent. Nausea and heartburn with aspirin (option C) are expected and managed with enteric-coated
formulations or PPIs. A heart rate of 56 bpm (option D) in a client on beta-blockers post-MI is acceptable if
asymptomatic and systolic BP > 90 mm Hg. ATI strategy: post-PCI clients on DAPT have a quantifiable bleeding risk;
any sign of internal bleeding (melena, hematemesis, hematuria, altered mental status with drop in H/H, hypotension) is
a "red flag" requiring immediate escalation. The pattern: GI bleeding signs in clients on anticoagulants/antiplatelets =
highest priority.
Q7: A 72-year-old client with chronic atrial fibrillation is receiving warfarin 5 mg daily. The INR today is
4.8 (therapeutic range 2.0-3.0 for atrial fibrillation). The client denies bleeding. Which provider order
should the nurse anticipate?
A. Administer 10 mg vitamin K IV push immediately
B. Hold the next warfarin dose and recheck INR in 24 hours [CORRECT]
C. Administer 4 units of fresh frozen plasma over 30 minutes
D. Continue warfarin at the same dose and recheck INR in 7 days
Correct Answer: B
Nursing Education | Form B Page 3
, ATI Medical-Surgical Nursing Proctored Exam 2026/2027 - Form B 90 Questions | Cognitive: 30% Recall / 50% Application / 20% Analysis
Rationale: Per the American College of Chest Physicians (CHEST) guidelines, an INR between 4.5 and 10 without
bleeding requires holding the next dose(s) of warfarin and monitoring closely, with optional low-dose oral vitamin K
(1-2.5 mg). IV push vitamin K (option A) is reserved for serious or life-threatening bleeding with markedly elevated
INR (>10) due to rapid reversal but risk of anaphylaxis and "warfarin resistance" for weeks. Fresh frozen plasma
(option C) is indicated only for active bleeding with elevated INR. Continuing the same dose (option D) would worsen
the supratherapeutic state. ATI strategy: do not "over-treat" asymptomatic INR elevations; minimal intervention is the
standard. The nurse anticipates the most conservative guideline-based action: hold and recheck. Test-taking: when
"without bleeding" appears in the stem, the answer is almost always "hold and monitor," not "administer antidote."
Q8: A 24-year-old female client reports profound fatigue, pallor, and brittle nails for the past 3 months.
Her hemoglobin is 8.6 g/dL, MCV 72 fL, and serum ferritin 8 ng/mL. She reports heavy menstrual periods
(lasting 7-9 days). Which intervention is MOST appropriate for the nurse to include in the plan of care?
A. Administer a 1-unit packed red blood cell transfusion over 4 hours
B. Teach the client to take oral ferrous sulfate 325 mg with orange juice on an empty stomach
[CORRECT]
C. Instruct the client to consume iron-rich foods only and recheck the CBC in 6 months
D. Recommend an iron dextran IV infusion weekly for 8 weeks
Correct Answer: B
Rationale: The client has classic iron-deficiency anemia (low Hgb, microcytic MCV <80, low ferritin <15) caused by
heavy menstrual blood loss. The first-line treatment for stable iron-deficiency anemia is oral ferrous sulfate 325 mg
once to three times daily, taken on an empty stomach with vitamin C (ascorbic acid, e.g., orange juice) to enhance
absorption. Blood transfusion (option A) is reserved for hemodynamically unstable clients or Hgb below 7 g/dL with
symptoms of tissue hypoxia. Diet alone (option C) is insufficient to replete iron stores in the setting of ongoing blood
loss. IV iron (option D) is reserved for clients with malabsorption, severe intolerance to oral iron, or chronic kidney
disease. ATI strategy: stable iron-deficiency anemia in a menstruating female is treated with oral ferrous sulfate +
vitamin C; teach clients that black stools are expected and to continue therapy for 3-6 months after hemoglobin
normalizes to replete iron stores.
Q9: A 16-year-old African American male client presents to the emergency department with severe pain in
the lower back and both knees, rating the pain 9/10. He has a history of sickle cell disease. Vital signs: T
38.4°C (101.1°F), HR 124, BP 104/64, RR 26, SpO2 92% on room air. Which provider order should the
nurse implement FIRST?
A. Administer morphine 4 mg IV push now and every 3 hours PRN for pain
B. Start IV 0.9% normal saline at 250 mL/hr and apply warm moist packs to painful joints
C. Obtain blood, urine, and sputum cultures and administer ceftriaxone IV
D. Administer 2 units of oxygen via nasal cannula and titrate to keep SpO2 ≥ 95% [CORRECT]
Correct Answer: D
Rationale: The client is in an acute vaso-occlusive sickle cell crisis with hypoxia (SpO2 92%). Hypoxia is the most
common trigger of sickling; therefore the PRIORITY is supplemental oxygen to maintain SpO2 at or above 95%,
which reduces sickling and improves tissue oxygenation. All other interventions (IV fluids, pain control, antibiotics)
are essential and concurrent, but oxygen addresses the ABCs (Airway/Breathing first) and the underlying
pathophysiology. Pain control (option A) and IV fluids (option B) follow closely, but in ATI prioritization, when ABC
compromise exists, that intervention takes precedence. Antibiotics (option C) are appropriate given the fever, which is
concerning for infection-triggered crisis, but stabilizing oxygenation comes first. ATI strategy: acute prioritization
uses the ABC framework; hypoxia is always addressed first. Pain, while severe, is treated after stabilization of
oxygenation in crisis.
Nursing Education | Form B Page 4
