ATI RN MED-SURG
PROCTORED EXAM |
COMPLETE TEST
BANK | VERSIONS
1-5 | LATEST
2025/2026
,DOMAIN 1: CARDIOVASCULAR SYSTEM
Question 1
A nurse is assessing a client who has heart failure. Which of the following findings is
the priority for the nurse to report to the provider?
A) Crackles heard in the lung bases
B) Weight gain of 1 kg (2.2 lb) in 24 hours
C) Heart rate of 110/min
D) Urine output of 30 mL/hr
Correct Answer: A
Rationale:
Correct (A): Crackles in the lung bases indicate pulmonary congestion, which is a
sign of acute worsening of heart failure and can progress to pulmonary edema and
respiratory failure if not treated immediately. This is the priority finding because it
directly affects gas exchange and oxygenation. The nurse should report crackles to
the provider immediately for rapid intervention such as diuretic administration.
Incorrect (B): Weight gain of 1 kg in 24 hours indicates fluid retention but is not
as immediately life-threatening as pulmonary congestion.
, Incorrect (C): Tachycardia is expected in heart failure due to compensatory
mechanisms but is not the priority over respiratory findings.
Incorrect (D): Urine output of 30 mL/hr is within normal range (minimum 30
mL/hr) and is not concerning.
Study Tip: "Heart failure priority = crackles (pulmonary edema). Report
immediately."
Question 2
A nurse is caring for a client who is 2 hours postoperative following a cardiac
catheterization. Which of the following actions should the nurse take?
A) Keep the affected leg straight
B) Elevate the head of the bed to 45 degrees
C) Apply pressure to the insertion site every 30 minutes
D) Encourage range of motion exercises to the affected leg
Correct Answer: A
Rationale:
Correct (A): The client should keep the affected leg straight (extended) for 4-6
hours after cardiac catheterization to prevent bleeding or hematoma formation at
the femoral insertion site. Keeping the leg straight allows the arterial puncture site
to heal and prevents dislodgement of the clot that forms over the puncture site.
Incorrect (B): The head of the bed should be flat or elevated no more than 30
degrees to maintain femoral artery pressure.
, Incorrect (C): Pressure should be applied only if bleeding occurs; routine
pressure every 30 minutes may dislodge the clot.
Incorrect (D): ROM exercises to the affected leg are contraindicated because
movement can dislodge the clot and cause bleeding.
StudyTip: "Post-cardiac catheterization = keep affected leg straight, flat or low HOB,
monitor insertion site."
Question 3
A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
A) Jugular vein distension
B) Peripheral edema
C) Crackles in the lungs
D) Hepatomegaly
Correct Answer: C
Rationale:
Correct (C): Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion. Crackles (rales) in the lung bases are a
classic sign of pulmonary congestion from left-sided heart failure. The nurse should
also expect dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and cough.
Incorrect (A): Jugular vein distension is a sign of right-sided heart failure
(systemic venous congestion).
PROCTORED EXAM |
COMPLETE TEST
BANK | VERSIONS
1-5 | LATEST
2025/2026
,DOMAIN 1: CARDIOVASCULAR SYSTEM
Question 1
A nurse is assessing a client who has heart failure. Which of the following findings is
the priority for the nurse to report to the provider?
A) Crackles heard in the lung bases
B) Weight gain of 1 kg (2.2 lb) in 24 hours
C) Heart rate of 110/min
D) Urine output of 30 mL/hr
Correct Answer: A
Rationale:
Correct (A): Crackles in the lung bases indicate pulmonary congestion, which is a
sign of acute worsening of heart failure and can progress to pulmonary edema and
respiratory failure if not treated immediately. This is the priority finding because it
directly affects gas exchange and oxygenation. The nurse should report crackles to
the provider immediately for rapid intervention such as diuretic administration.
Incorrect (B): Weight gain of 1 kg in 24 hours indicates fluid retention but is not
as immediately life-threatening as pulmonary congestion.
, Incorrect (C): Tachycardia is expected in heart failure due to compensatory
mechanisms but is not the priority over respiratory findings.
Incorrect (D): Urine output of 30 mL/hr is within normal range (minimum 30
mL/hr) and is not concerning.
Study Tip: "Heart failure priority = crackles (pulmonary edema). Report
immediately."
Question 2
A nurse is caring for a client who is 2 hours postoperative following a cardiac
catheterization. Which of the following actions should the nurse take?
A) Keep the affected leg straight
B) Elevate the head of the bed to 45 degrees
C) Apply pressure to the insertion site every 30 minutes
D) Encourage range of motion exercises to the affected leg
Correct Answer: A
Rationale:
Correct (A): The client should keep the affected leg straight (extended) for 4-6
hours after cardiac catheterization to prevent bleeding or hematoma formation at
the femoral insertion site. Keeping the leg straight allows the arterial puncture site
to heal and prevents dislodgement of the clot that forms over the puncture site.
Incorrect (B): The head of the bed should be flat or elevated no more than 30
degrees to maintain femoral artery pressure.
, Incorrect (C): Pressure should be applied only if bleeding occurs; routine
pressure every 30 minutes may dislodge the clot.
Incorrect (D): ROM exercises to the affected leg are contraindicated because
movement can dislodge the clot and cause bleeding.
StudyTip: "Post-cardiac catheterization = keep affected leg straight, flat or low HOB,
monitor insertion site."
Question 3
A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect?
A) Jugular vein distension
B) Peripheral edema
C) Crackles in the lungs
D) Hepatomegaly
Correct Answer: C
Rationale:
Correct (C): Left-sided heart failure causes blood to back up into the pulmonary
circulation, leading to pulmonary congestion. Crackles (rales) in the lung bases are a
classic sign of pulmonary congestion from left-sided heart failure. The nurse should
also expect dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and cough.
Incorrect (A): Jugular vein distension is a sign of right-sided heart failure
(systemic venous congestion).
