ATI RN Adult Medical-Surgical Proctored Exam
— Exam Questions with Correct Answers
(VerifiedAnswers) plus Rationales 2026 Q&A
Instant Download PDF
1. A nurse is caring for a client who has heart failure and
reports increasing shortness of breath. Which finding requires
the nurse's immediate attention?
A. Weight gain of 1 lb (0.45 kg) over 24 hr
B. Mild bilateral ankle edema
C. Crackles throughout both lung fields with severe dyspnea
D. Fatigue after walking to the bathroom
Rationale: Crackles accompanied by severe dyspnea suggest
acute pulmonary congestion from worsening heart failure.
Pulmonary edema can rapidly impair oxygenation and become
life-threatening, so airway and breathing take priority. A small
daily weight gain and mild dependent edema are important
findings that indicate fluid retention, but they are not as
immediately threatening as evidence of pulmonary edema. The
nurse should position the client upright, assess oxygenation,
administer oxygen as prescribed, and promptly notify the
provider or initiate emergency measures according to the
client's condition.
,2. A client receiving digoxin has a potassium level of 3.0 mEq/L
(3.0 mmol/L). Which action should the nurse take?
A. Administer the digoxin as prescribed
B. Restrict the client's potassium intake
C. Administer an additional dose of digoxin
D. Notify the provider about the potassium level before
administering digoxin
Rationale: Hypokalemia increases the risk of digoxin toxicity
because potassium normally competes with digoxin for binding
sites on cardiac cells. A potassium level of 3.0 mEq/L is below
the expected range and places the client at increased risk for
dysrhythmias and toxicity. The nurse should hold the medication
according to applicable institutional parameters and notify the
provider. Manifestations of digoxin toxicity can include nausea,
vomiting, anorexia, confusion, visual disturbances, and cardiac
dysrhythmias.
3. A nurse is assessing a client who reports crushing substernal
chest pain radiating to the left arm. Which action has the
highest priority?
A. Encourage ambulation to assess activity tolerance
B. Obtain a routine dietary history
C. Assess vital signs and obtain a 12-lead ECG promptly
D. Ask the client to rate their pain after 1 hr
,Rationale: Crushing substernal chest pain with radiation is
concerning for acute coronary syndrome. Rapid assessment of
hemodynamic stability and acquisition of a 12-lead ECG are
essential because early identification of myocardial ischemia
guides urgent treatment. Waiting an hour or encouraging
activity could delay recognition and treatment of myocardial
injury. The nurse should also establish IV access, obtain
prescribed cardiac laboratory studies, administer ordered
therapies, and continuously reassess the client's condition.
4. A client taking warfarin asks how to maintain a stable
response to therapy. Which statement indicates correct
understanding?
A. "I should completely avoid foods containing vitamin K."
B. "I can double my dose if I miss one."
C. "I should keep my intake of vitamin K-containing foods
consistent."
D. "I do not need blood tests while taking this medication."
Rationale: Warfarin therapy is affected by vitamin K intake.
Clients do not generally need to eliminate vitamin K-containing
foods; instead, they should maintain a consistent dietary pattern
so anticoagulation remains predictable. The client should never
independently double a missed dose unless specifically
instructed. Regular monitoring of the prescribed coagulation
, parameter, usually INR, is essential because excessive
anticoagulation increases bleeding risk.
5. A client develops a sudden facial droop and weakness of the
right arm. Which action should the nurse take first?
A. Give the client oral fluids
B. Place the client flat in bed
C. Determine the time the symptoms began and activate the
stroke response
D. Administer an oral antihypertensive medication immediately
Rationale: Sudden unilateral weakness and facial drooping are
classic warning signs of an acute stroke. The exact time the
client was last known to be well is critical because eligibility for
time-sensitive reperfusion therapies depends on symptom
timing and other clinical factors. The nurse should activate the
facility's stroke protocol and rapidly assess airway, breathing,
circulation, blood glucose, neurologic status, and other relevant
findings. Oral intake should be avoided until swallowing safety is
established.
6. A client with peripheral arterial disease reports severe leg
pain while walking that is relieved by rest. Which instruction
should the nurse provide?
A. "Keep your legs elevated above heart level throughout the
day."
B. "Apply heating pads directly to your feet."
— Exam Questions with Correct Answers
(VerifiedAnswers) plus Rationales 2026 Q&A
Instant Download PDF
1. A nurse is caring for a client who has heart failure and
reports increasing shortness of breath. Which finding requires
the nurse's immediate attention?
A. Weight gain of 1 lb (0.45 kg) over 24 hr
B. Mild bilateral ankle edema
C. Crackles throughout both lung fields with severe dyspnea
D. Fatigue after walking to the bathroom
Rationale: Crackles accompanied by severe dyspnea suggest
acute pulmonary congestion from worsening heart failure.
Pulmonary edema can rapidly impair oxygenation and become
life-threatening, so airway and breathing take priority. A small
daily weight gain and mild dependent edema are important
findings that indicate fluid retention, but they are not as
immediately threatening as evidence of pulmonary edema. The
nurse should position the client upright, assess oxygenation,
administer oxygen as prescribed, and promptly notify the
provider or initiate emergency measures according to the
client's condition.
,2. A client receiving digoxin has a potassium level of 3.0 mEq/L
(3.0 mmol/L). Which action should the nurse take?
A. Administer the digoxin as prescribed
B. Restrict the client's potassium intake
C. Administer an additional dose of digoxin
D. Notify the provider about the potassium level before
administering digoxin
Rationale: Hypokalemia increases the risk of digoxin toxicity
because potassium normally competes with digoxin for binding
sites on cardiac cells. A potassium level of 3.0 mEq/L is below
the expected range and places the client at increased risk for
dysrhythmias and toxicity. The nurse should hold the medication
according to applicable institutional parameters and notify the
provider. Manifestations of digoxin toxicity can include nausea,
vomiting, anorexia, confusion, visual disturbances, and cardiac
dysrhythmias.
3. A nurse is assessing a client who reports crushing substernal
chest pain radiating to the left arm. Which action has the
highest priority?
A. Encourage ambulation to assess activity tolerance
B. Obtain a routine dietary history
C. Assess vital signs and obtain a 12-lead ECG promptly
D. Ask the client to rate their pain after 1 hr
,Rationale: Crushing substernal chest pain with radiation is
concerning for acute coronary syndrome. Rapid assessment of
hemodynamic stability and acquisition of a 12-lead ECG are
essential because early identification of myocardial ischemia
guides urgent treatment. Waiting an hour or encouraging
activity could delay recognition and treatment of myocardial
injury. The nurse should also establish IV access, obtain
prescribed cardiac laboratory studies, administer ordered
therapies, and continuously reassess the client's condition.
4. A client taking warfarin asks how to maintain a stable
response to therapy. Which statement indicates correct
understanding?
A. "I should completely avoid foods containing vitamin K."
B. "I can double my dose if I miss one."
C. "I should keep my intake of vitamin K-containing foods
consistent."
D. "I do not need blood tests while taking this medication."
Rationale: Warfarin therapy is affected by vitamin K intake.
Clients do not generally need to eliminate vitamin K-containing
foods; instead, they should maintain a consistent dietary pattern
so anticoagulation remains predictable. The client should never
independently double a missed dose unless specifically
instructed. Regular monitoring of the prescribed coagulation
, parameter, usually INR, is essential because excessive
anticoagulation increases bleeding risk.
5. A client develops a sudden facial droop and weakness of the
right arm. Which action should the nurse take first?
A. Give the client oral fluids
B. Place the client flat in bed
C. Determine the time the symptoms began and activate the
stroke response
D. Administer an oral antihypertensive medication immediately
Rationale: Sudden unilateral weakness and facial drooping are
classic warning signs of an acute stroke. The exact time the
client was last known to be well is critical because eligibility for
time-sensitive reperfusion therapies depends on symptom
timing and other clinical factors. The nurse should activate the
facility's stroke protocol and rapidly assess airway, breathing,
circulation, blood glucose, neurologic status, and other relevant
findings. Oral intake should be avoided until swallowing safety is
established.
6. A client with peripheral arterial disease reports severe leg
pain while walking that is relieved by rest. Which instruction
should the nurse provide?
A. "Keep your legs elevated above heart level throughout the
day."
B. "Apply heating pads directly to your feet."
