MedSurg ATI Exam
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of
the following ECG abnormalities should the nurse recognize as atrial flutter?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSB.
the nurse should interpret this finding as atrial flutter, which indicates a lack o fconduction
between the atria and ventricles. The additional atrial beats are not conducting.
Which one of these rhythms indicates ventricular tachycardia?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSD
Which one of the following rates indicates normal sinus rhythm?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSA
Which one of the following indicates a PVC?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSC
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following
findings should the nurse expect?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSD.
the client who has aplastic anemia will have these manifestations. Dyspnea on exertion can
also be present. In aplastic anemia, all 3 major blood components (RBC, WBC, platelets) are
reduced or absent, known as pancytopenia. Manifestations usually develop gradually.
Which one of the following choices are manifestations of pernicious anemia?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSB
,Which one of the following choices are manifestations of sickle cell anemia?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSC. An enlarged spleen is also present
A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type
is B positive. WHich of the following actions should the nurse take?
A. Contimue to monitor for manifestations of a transfusion reaction.
B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.
C. continue the transfusion and repeat the type and crossmatch
D. prepare to administer a dose of diphenhydramine IV. - ANSB.
a client who receives FFP that is not compatible can experience a hemolytic transfusion
reaction. the nurse should stop the transfusion and infuse 0.9 NaCl with new tubing.
A client whose blood type is B can only receive type B of AB plasma.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client
reports shortness of breath on exertion. Which of the following conditions should the nurse
expect?
A. Increased cardiac output
B. Increased pulmonary congestion
C. Decreased left atria pressure
D. Decreased pulmonary artery pressure - ANSB.
pulmonary congestion occurs due to right sided heart failure. Because of the defect in the
mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in
pulmonary artery pressure, and the hypertrophy of the right ventricle occurs. In this case,
dyspnea is an indication of pulmonary congestion and right sided heart failure.
Pulmonary artery pressure increases as a result of back-up from stenosis of the mitral valve.
Cardiac output is decreased because the left ventricle is receiving insufficient blood volume
to pump out.
A nurse is assessing a client who has pericarditis. Which of the following manifestations
should the nurse expect?
A. Bradycardia with S-T segment depression
B. Relief of chest pain with deep inspiration.
C. Dyspnea with hiccups
D. Chest pain that increases when sitting upright. - ANSC.
A client with pericarditis will experience dyspnea, hiccups, and a nonproductive cough.
These manifestations can indicate heart failure from pericardial compression due to
constrictive pericarditis or cardiac tamponade.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin
alfa. Which of the following information should the nurse include in the teaching?
A. hospitalization is required when administering each treatment.
B. The maximum effect of the medication will occur in 6 months
C. Hypertension is a common adverse effect of this medication.
D. Blood transfusions are needed with each treatment. - ANSC.
,Hypertension is a common adverse effect of epoetin alfa because of the rise in production of
erythrocytes and other RBC types. Epoetin alfa is a synthetic version of human
erythropoeitin.
Epoetin alfa is self-administered at home and the effects will occur in 2-3 months.
A nurse is reviewing a client's repeat laboratory results 4 hours after administering FFP.
Which of the following lab results should the nurse review?
A. Prothrombin time
B. WBC count
C. Platelet count
D. Hematocrit - ANSA.
FFP is rich in clotting factors and is administered to treat acute clotting disorders. The
desired effect is a decreased prothrombin time.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder.
Which of the following manifestations should the nurse expect? (SATA)
A. Jugular vein distension
B. Moist crackles
C. Postural hypotension
D. Increased HR
E. Fever - ANSABD
A nurse is monitoring a client who had a myocardial infarction. For which of the following
complications should the nurse monitor in the first 24 hr?
A. Infective endocarditis.
B. Pericarditis
C. Ventricular Dysrhythmias
D. Pulmonary Emboli - ANSC.
After an MI, the electrical conduction system of the heart can be irritable and prone to
dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal
conduction patterns of the heart's electrical system.
A nurse is planning care for a client who has pernicious anemia. Which of the following
interventions should the nurse include in the plan?
A. Administer ferrous sulfate
B. Increase dietary intake of folic acid.
C. Initiate weekly vitamin B12 injections.
D. Initiate a blood transfusion - ANSC. the nurse should initiate B12 injections for a client
with pernicious anemia, then decrease to monthly. Pernicious anemia is caused by a lack of
intrinsic factor needed to absorb vitamin B12 in teh GI tract.
A nurse is planning care for a client who has iron deficiency anemia. Which of the following
interventions should the nurse include in the plan?
A. Administer ferrous sulfate
B. Increase dietary intake of folic acid.
C. Initiate weekly vitamin B12 injections.
D. Initiate a blood transfusion - ANSA
, A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood,
the nurse should administer which of the following solutions?
A. 0.45% NaCl
B. D5 in 0.9% NaCl
C. D10W
D. 0.9% NaCl - ANSD.
A nurse is assessing for cardiac tamponade on a client who had a coronary artery bypass
graft. Which of the following actions should the nurse take?
A. Check for hypertension
B. Auscultate for loud, bounding heart sounds
C. Auscultate blood pressure for pulsus paradoxus.
D. Check for a pulse deficit - ANSC.
The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood
pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because
of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
A client who has cardiac tamponade will have hypertension because of the sudden decrease
in cardiac output from the fluid compressing the atria and the ventricles. Heart sounds will be
muffled.
A nurse is assessing a client who has Guillain-Barre syndrome. WHich of the following
findings should the nurse expect?
A. Tonic clonic seizures
B. Report of a severe headache
C. Weakness of the lower extremities
D. Decreased level of consciousness - ANSC.
Guillain-Barre syndrome is also called inflammatory demyelinating polyneuropathy. This is
an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of
ascending weakness and paralysis, starting at the lower extremities, and can advance to the
upper extremities.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma.
The nurse should anticipate the client to report which of the following manifestations?
A. Multiple floaters
B. Flashes of light in front of the eye
C. Severe eye pain
D. Double vision - ANSC.
Other manifestations can include report of halos around lights, blurred vision, headache,
brow pain, and nausea and vomiting.
A nurse is assessing a client who has a new diagnosis of a detached retina. The nurse
should anticipate the client to report which of the following manifestations? (SATA)
A. Multiple floaters
B. Flashes of light in front of the eye
C. Severe eye pain
D. Double vision - ANSAB
A nurse on a telemetry unit is caring for a client who has an irregular radial pulse. Which of
the following ECG abnormalities should the nurse recognize as atrial flutter?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSB.
the nurse should interpret this finding as atrial flutter, which indicates a lack o fconduction
between the atria and ventricles. The additional atrial beats are not conducting.
Which one of these rhythms indicates ventricular tachycardia?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSD
Which one of the following rates indicates normal sinus rhythm?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSA
Which one of the following indicates a PVC?
A. P waves occurring at 0.16 sec before each QRS complex
B. Atrial rate of 300/min with QRS complex of 80/min
C. Ventricular rate of 82/min with an atrial rate of 80/min
D. An irregular ventricular rate of 125/min with a wide QRS pattern - ANSC
A nurse is assessing a client for manifestations of aplastic anemia. Which of the following
findings should the nurse expect?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSD.
the client who has aplastic anemia will have these manifestations. Dyspnea on exertion can
also be present. In aplastic anemia, all 3 major blood components (RBC, WBC, platelets) are
reduced or absent, known as pancytopenia. Manifestations usually develop gradually.
Which one of the following choices are manifestations of pernicious anemia?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSB
,Which one of the following choices are manifestations of sickle cell anemia?
A. Plethoric appearance of facial skin
B. Glossitis and weight loss
C. Jaundice and an enlarged liver
D. Petechiae and ecchymosis - ANSC. An enlarged spleen is also present
A nurse is transfusing a unit of O-negative fresh frozen plasma to a client whose blood type
is B positive. WHich of the following actions should the nurse take?
A. Contimue to monitor for manifestations of a transfusion reaction.
B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution.
C. continue the transfusion and repeat the type and crossmatch
D. prepare to administer a dose of diphenhydramine IV. - ANSB.
a client who receives FFP that is not compatible can experience a hemolytic transfusion
reaction. the nurse should stop the transfusion and infuse 0.9 NaCl with new tubing.
A client whose blood type is B can only receive type B of AB plasma.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client
reports shortness of breath on exertion. Which of the following conditions should the nurse
expect?
A. Increased cardiac output
B. Increased pulmonary congestion
C. Decreased left atria pressure
D. Decreased pulmonary artery pressure - ANSB.
pulmonary congestion occurs due to right sided heart failure. Because of the defect in the
mitral valve, the left atrial pressure rises, the left atrium dilates, there is an increase in
pulmonary artery pressure, and the hypertrophy of the right ventricle occurs. In this case,
dyspnea is an indication of pulmonary congestion and right sided heart failure.
Pulmonary artery pressure increases as a result of back-up from stenosis of the mitral valve.
Cardiac output is decreased because the left ventricle is receiving insufficient blood volume
to pump out.
A nurse is assessing a client who has pericarditis. Which of the following manifestations
should the nurse expect?
A. Bradycardia with S-T segment depression
B. Relief of chest pain with deep inspiration.
C. Dyspnea with hiccups
D. Chest pain that increases when sitting upright. - ANSC.
A client with pericarditis will experience dyspnea, hiccups, and a nonproductive cough.
These manifestations can indicate heart failure from pericardial compression due to
constrictive pericarditis or cardiac tamponade.
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin
alfa. Which of the following information should the nurse include in the teaching?
A. hospitalization is required when administering each treatment.
B. The maximum effect of the medication will occur in 6 months
C. Hypertension is a common adverse effect of this medication.
D. Blood transfusions are needed with each treatment. - ANSC.
,Hypertension is a common adverse effect of epoetin alfa because of the rise in production of
erythrocytes and other RBC types. Epoetin alfa is a synthetic version of human
erythropoeitin.
Epoetin alfa is self-administered at home and the effects will occur in 2-3 months.
A nurse is reviewing a client's repeat laboratory results 4 hours after administering FFP.
Which of the following lab results should the nurse review?
A. Prothrombin time
B. WBC count
C. Platelet count
D. Hematocrit - ANSA.
FFP is rich in clotting factors and is administered to treat acute clotting disorders. The
desired effect is a decreased prothrombin time.
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder.
Which of the following manifestations should the nurse expect? (SATA)
A. Jugular vein distension
B. Moist crackles
C. Postural hypotension
D. Increased HR
E. Fever - ANSABD
A nurse is monitoring a client who had a myocardial infarction. For which of the following
complications should the nurse monitor in the first 24 hr?
A. Infective endocarditis.
B. Pericarditis
C. Ventricular Dysrhythmias
D. Pulmonary Emboli - ANSC.
After an MI, the electrical conduction system of the heart can be irritable and prone to
dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal
conduction patterns of the heart's electrical system.
A nurse is planning care for a client who has pernicious anemia. Which of the following
interventions should the nurse include in the plan?
A. Administer ferrous sulfate
B. Increase dietary intake of folic acid.
C. Initiate weekly vitamin B12 injections.
D. Initiate a blood transfusion - ANSC. the nurse should initiate B12 injections for a client
with pernicious anemia, then decrease to monthly. Pernicious anemia is caused by a lack of
intrinsic factor needed to absorb vitamin B12 in teh GI tract.
A nurse is planning care for a client who has iron deficiency anemia. Which of the following
interventions should the nurse include in the plan?
A. Administer ferrous sulfate
B. Increase dietary intake of folic acid.
C. Initiate weekly vitamin B12 injections.
D. Initiate a blood transfusion - ANSA
, A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood,
the nurse should administer which of the following solutions?
A. 0.45% NaCl
B. D5 in 0.9% NaCl
C. D10W
D. 0.9% NaCl - ANSD.
A nurse is assessing for cardiac tamponade on a client who had a coronary artery bypass
graft. Which of the following actions should the nurse take?
A. Check for hypertension
B. Auscultate for loud, bounding heart sounds
C. Auscultate blood pressure for pulsus paradoxus.
D. Check for a pulse deficit - ANSC.
The client who has cardiac tamponade will have pulsus paradoxus when the systolic blood
pressure is at least 10 mmHg higher on expiration than on inspiration. This occurs because
of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.
A client who has cardiac tamponade will have hypertension because of the sudden decrease
in cardiac output from the fluid compressing the atria and the ventricles. Heart sounds will be
muffled.
A nurse is assessing a client who has Guillain-Barre syndrome. WHich of the following
findings should the nurse expect?
A. Tonic clonic seizures
B. Report of a severe headache
C. Weakness of the lower extremities
D. Decreased level of consciousness - ANSC.
Guillain-Barre syndrome is also called inflammatory demyelinating polyneuropathy. This is
an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of
ascending weakness and paralysis, starting at the lower extremities, and can advance to the
upper extremities.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma.
The nurse should anticipate the client to report which of the following manifestations?
A. Multiple floaters
B. Flashes of light in front of the eye
C. Severe eye pain
D. Double vision - ANSC.
Other manifestations can include report of halos around lights, blurred vision, headache,
brow pain, and nausea and vomiting.
A nurse is assessing a client who has a new diagnosis of a detached retina. The nurse
should anticipate the client to report which of the following manifestations? (SATA)
A. Multiple floaters
B. Flashes of light in front of the eye
C. Severe eye pain
D. Double vision - ANSAB
