ATI RN Medical-Surgical Proctored Exam 2019
Retake Correct questions and answers
SECTION 1: CARDIOVASCULAR SYSTEM
Question 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. Weight loss of 1 kg (2.2 lb) in 24 hours
B. Heart rate of 56/min
C. Serum potassium level of 3.1 mEq/L
D. Urine output of 20 mL/hr
Correct Answer: A. Weight loss of 1 kg (2.2 lb) in 24 hours
Rationale: A weight loss of 0.5–1 kg (1–2 lb) per day is an expected
therapeutic response to diuretic therapy in heart failure, indicating effective fluid
mobilization. Option B (bradycardia) may indicate digoxin toxicity. Option C
(hypokalemia) is an adverse effect of loop diuretics, not a therapeutic response.
Option D (oliguria) indicates inadequate diuresis or renal impairment.
Question 2
A nurse is assessing a client who has a new diagnosis of atrial fibrillation. Which of
the following findings should the nurse expect?
A. Regular apical pulse with a rate of 88/min
B. Pulse deficit between apical and radial pulses
C. Blood pressure of 180/100 mm Hg
D. Jugular venous distention
Correct Answer: B. Pulse deficit between apical and radial pulses
, Rationale: Atrial fibrillation causes an irregularly irregular rhythm with
ineffective atrial contractions, leading to a pulse deficit (apical rate exceeds radial
rate). Option A is incorrect because the rhythm is irregular. Option C is not a
specific finding for atrial fibrillation. Option D is associated with right-sided heart
failure, not necessarily atrial fibrillation.
Question 3
A nurse is caring for a client who is receiving heparin IV infusion. The nurse should
monitor which of the following laboratory values to evaluate the therapeutic
effect of heparin?
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 therapeutic effect of unfractionated
heparin. The therapeutic range is typically 1.5–2.5 times the control value. PT/INR
(Options A and B) are used to monitor warfarin therapy. Platelet count (Option D)
is monitored for heparin-induced thrombocytopenia (HIT), but it does not
evaluate therapeutic effect.
Question 4
A nurse is teaching a client who has a new prescription for nitroglycerin sublingual
tablets. Which of the following instructions should the nurse include? (Select All
That Apply)
A. "Take one tablet at the onset of chest pain."
B. "Call 911 if the pain is not relieved after 5 minutes."
C. "Store the tablets in a dark, glass container."
,D. "Swallow the tablet with a full glass of water."
E. "Take up to three tablets, 5 minutes apart."
Correct Answers: A, B, C, E
Rationale: A: Nitroglycerin is taken at the onset of chest pain. B: If pain
persists after one tablet and 5 minutes, the client should call 911. C: Nitroglycerin
is light-sensitive and should be stored in a dark, glass container. E: Up to three
tablets may be taken 5 minutes apart. D is incorrect—sublingual tablets are placed
under the tongue, not swallowed.
Question 5
A nurse is assessing a client who has left-sided heart failure. Which of the
following findings should the nurse expect?
A. Dependent edema
B. Jugular venous distention
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion, manifesting
as crackles, dyspnea, and orthopnea. Options A, B, and D are manifestations of
right-sided heart failure due to systemic venous congestion.
Question 6
A nurse is caring for a client who has a blood pressure of 188/102 mm Hg and
reports a severe headache. Which of the following actions should the nurse take
first?
A. Administer an antihypertensive medication
B. Assess for neurological deficits
, C. Obtain a repeat blood pressure reading
D. Place the client in a supine position
Correct Answer: B. Assess for neurological deficits
Rationale: The client is experiencing a hypertensive emergency with a severe
headache, which may indicate increased intracranial pressure or stroke. The
priority is to assess neurological status to detect life-threatening complications.
Administering medication (A) may be appropriate but requires a prescription and
should follow assessment. Option C delays necessary assessment. Option D is
incorrect—the client should be placed in a semi-Fowler's position to promote
venous return and reduce intracranial pressure.
Question 7
A nurse is reviewing the laboratory results of a client who is taking warfarin. The
client's INR is 5.2. Which of the following actions should the nurse anticipate?
A. Administer vitamin K (phytonadione)
B. Increase the warfarin dose
C. Administer protamine sulfate
D. Continue the current dose
Correct Answer: A. Administer vitamin K (phytonadione)
Rationale: An INR of 5.2 is above the therapeutic range (2–3 for most
conditions), indicating an increased risk of bleeding. Vitamin K is the antidote for
warfarin overdose. Option B would further increase bleeding risk. Option C
(protamine sulfate) is the antidote for heparin. Option D is incorrect because the
INR is dangerously elevated.
Question 8
Retake Correct questions and answers
SECTION 1: CARDIOVASCULAR SYSTEM
Question 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. Weight loss of 1 kg (2.2 lb) in 24 hours
B. Heart rate of 56/min
C. Serum potassium level of 3.1 mEq/L
D. Urine output of 20 mL/hr
Correct Answer: A. Weight loss of 1 kg (2.2 lb) in 24 hours
Rationale: A weight loss of 0.5–1 kg (1–2 lb) per day is an expected
therapeutic response to diuretic therapy in heart failure, indicating effective fluid
mobilization. Option B (bradycardia) may indicate digoxin toxicity. Option C
(hypokalemia) is an adverse effect of loop diuretics, not a therapeutic response.
Option D (oliguria) indicates inadequate diuresis or renal impairment.
Question 2
A nurse is assessing a client who has a new diagnosis of atrial fibrillation. Which of
the following findings should the nurse expect?
A. Regular apical pulse with a rate of 88/min
B. Pulse deficit between apical and radial pulses
C. Blood pressure of 180/100 mm Hg
D. Jugular venous distention
Correct Answer: B. Pulse deficit between apical and radial pulses
, Rationale: Atrial fibrillation causes an irregularly irregular rhythm with
ineffective atrial contractions, leading to a pulse deficit (apical rate exceeds radial
rate). Option A is incorrect because the rhythm is irregular. Option C is not a
specific finding for atrial fibrillation. Option D is associated with right-sided heart
failure, not necessarily atrial fibrillation.
Question 3
A nurse is caring for a client who is receiving heparin IV infusion. The nurse should
monitor which of the following laboratory values to evaluate the therapeutic
effect of heparin?
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 therapeutic effect of unfractionated
heparin. The therapeutic range is typically 1.5–2.5 times the control value. PT/INR
(Options A and B) are used to monitor warfarin therapy. Platelet count (Option D)
is monitored for heparin-induced thrombocytopenia (HIT), but it does not
evaluate therapeutic effect.
Question 4
A nurse is teaching a client who has a new prescription for nitroglycerin sublingual
tablets. Which of the following instructions should the nurse include? (Select All
That Apply)
A. "Take one tablet at the onset of chest pain."
B. "Call 911 if the pain is not relieved after 5 minutes."
C. "Store the tablets in a dark, glass container."
,D. "Swallow the tablet with a full glass of water."
E. "Take up to three tablets, 5 minutes apart."
Correct Answers: A, B, C, E
Rationale: A: Nitroglycerin is taken at the onset of chest pain. B: If pain
persists after one tablet and 5 minutes, the client should call 911. C: Nitroglycerin
is light-sensitive and should be stored in a dark, glass container. E: Up to three
tablets may be taken 5 minutes apart. D is incorrect—sublingual tablets are placed
under the tongue, not swallowed.
Question 5
A nurse is assessing a client who has left-sided heart failure. Which of the
following findings should the nurse expect?
A. Dependent edema
B. Jugular venous distention
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C. Crackles in the lungs
Rationale: Left-sided heart failure leads to pulmonary congestion, manifesting
as crackles, dyspnea, and orthopnea. Options A, B, and D are manifestations of
right-sided heart failure due to systemic venous congestion.
Question 6
A nurse is caring for a client who has a blood pressure of 188/102 mm Hg and
reports a severe headache. Which of the following actions should the nurse take
first?
A. Administer an antihypertensive medication
B. Assess for neurological deficits
, C. Obtain a repeat blood pressure reading
D. Place the client in a supine position
Correct Answer: B. Assess for neurological deficits
Rationale: The client is experiencing a hypertensive emergency with a severe
headache, which may indicate increased intracranial pressure or stroke. The
priority is to assess neurological status to detect life-threatening complications.
Administering medication (A) may be appropriate but requires a prescription and
should follow assessment. Option C delays necessary assessment. Option D is
incorrect—the client should be placed in a semi-Fowler's position to promote
venous return and reduce intracranial pressure.
Question 7
A nurse is reviewing the laboratory results of a client who is taking warfarin. The
client's INR is 5.2. Which of the following actions should the nurse anticipate?
A. Administer vitamin K (phytonadione)
B. Increase the warfarin dose
C. Administer protamine sulfate
D. Continue the current dose
Correct Answer: A. Administer vitamin K (phytonadione)
Rationale: An INR of 5.2 is above the therapeutic range (2–3 for most
conditions), indicating an increased risk of bleeding. Vitamin K is the antidote for
warfarin overdose. Option B would further increase bleeding risk. Option C
(protamine sulfate) is the antidote for heparin. Option D is incorrect because the
INR is dangerously elevated.
Question 8
