ATI Medical-Surgical Practice Assessment —
Exam Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has acute heart failure. Which
finding requires the nurse's immediate intervention?
A. Bilateral 2+ ankle edema
B. Weight gain of 1 kg (2.2 lb) over 24 hr
C. Oxygen saturation of 84% on room air
D. Fatigue when ambulating to the bathroom
Correct answer: C. Oxygen saturation of 84% on room air
Rationale: An oxygen saturation of 84% indicates significant
hypoxemia and impaired gas exchange, making oxygenation the
immediate priority. The nurse should position the client to
facilitate breathing, administer oxygen as prescribed or
according to protocol, and rapidly reassess respiratory status.
Peripheral edema, rapid weight gain, and fatigue are important
manifestations of worsening heart failure, but they do not
,represent as immediate a threat to life as severe hypoxemia.
This question emphasizes the ABC priority framework: breathing
problems generally take precedence over less immediately
threatening manifestations.
Question 2
A client taking digoxin reports nausea, weakness, and seeing
yellow-green halos around lights. Which action should the
nurse take?
A. Administer the next dose with food
B. Encourage the client to increase potassium intake
independently
C. Hold the medication and notify the provider
D. Administer an additional dose if the heart rate is below
60/min
Correct answer: C. Hold the medication and notify the
provider
Rationale: Nausea, weakness, and visual disturbances such as
yellow-green halos are classic manifestations of digoxin toxicity.
The nurse should withhold the medication and notify the
provider so the client can be evaluated, including assessment of
the apical pulse and serum digoxin and electrolyte levels as
appropriate. Hypokalemia can increase the risk of digoxin
,toxicity, but the nurse should not independently prescribe
potassium supplementation. Giving another dose could worsen
toxicity and potentially precipitate dangerous dysrhythmias.
Question 3
A client with a history of myocardial infarction suddenly
develops severe chest pressure, diaphoresis, and shortness of
breath. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer prescribed sublingual nitroglycerin
C. Ask the client to rate the pain
D. Prepare the client for cardiac catheterization
Correct answer: A. Obtain a 12-lead ECG
Rationale: New severe chest pressure with diaphoresis and
dyspnea requires rapid evaluation for acute coronary syndrome.
A 12-lead ECG should be obtained promptly because it can
identify ischemic changes and determine whether an acute ST-
elevation myocardial infarction may be present. Pain
assessment remains important, and nitroglycerin may be
prescribed when appropriate, but rapid diagnostic assessment is
essential to guide treatment. Cardiac catheterization may
ultimately be necessary but is not the nurse's first independent
action before the immediate cardiac evaluation.
, Question 4
A client receiving a heparin infusion has a platelet count that
decreases substantially from baseline. Which complication
should the nurse suspect?
A. Iron-deficiency anemia
B. Heparin-induced thrombocytopenia
C. Disseminated intravascular coagulation caused by vitamin K
deficiency
D. Pernicious anemia
Correct answer: B. Heparin-induced thrombocytopenia
Rationale: A significant platelet decrease during heparin
therapy raises concern for heparin-induced thrombocytopenia
(HIT), an immune-mediated adverse reaction that paradoxically
increases the risk of thrombosis. The nurse should promptly
notify the provider and anticipate discontinuation of heparin
with evaluation for an alternative anticoagulant. HIT is not
simply a benign decrease in platelets; it can lead to life-
threatening venous or arterial thrombosis. Iron deficiency and
pernicious anemia do not explain an acute platelet decline
associated with heparin exposure.
Question 5
Exam Questions with Correct Answers
(VerifiedAnswers) Plus Rationales 2026 Q&A
Instant Download PDF
Question 1
A nurse is caring for a client who has acute heart failure. Which
finding requires the nurse's immediate intervention?
A. Bilateral 2+ ankle edema
B. Weight gain of 1 kg (2.2 lb) over 24 hr
C. Oxygen saturation of 84% on room air
D. Fatigue when ambulating to the bathroom
Correct answer: C. Oxygen saturation of 84% on room air
Rationale: An oxygen saturation of 84% indicates significant
hypoxemia and impaired gas exchange, making oxygenation the
immediate priority. The nurse should position the client to
facilitate breathing, administer oxygen as prescribed or
according to protocol, and rapidly reassess respiratory status.
Peripheral edema, rapid weight gain, and fatigue are important
manifestations of worsening heart failure, but they do not
,represent as immediate a threat to life as severe hypoxemia.
This question emphasizes the ABC priority framework: breathing
problems generally take precedence over less immediately
threatening manifestations.
Question 2
A client taking digoxin reports nausea, weakness, and seeing
yellow-green halos around lights. Which action should the
nurse take?
A. Administer the next dose with food
B. Encourage the client to increase potassium intake
independently
C. Hold the medication and notify the provider
D. Administer an additional dose if the heart rate is below
60/min
Correct answer: C. Hold the medication and notify the
provider
Rationale: Nausea, weakness, and visual disturbances such as
yellow-green halos are classic manifestations of digoxin toxicity.
The nurse should withhold the medication and notify the
provider so the client can be evaluated, including assessment of
the apical pulse and serum digoxin and electrolyte levels as
appropriate. Hypokalemia can increase the risk of digoxin
,toxicity, but the nurse should not independently prescribe
potassium supplementation. Giving another dose could worsen
toxicity and potentially precipitate dangerous dysrhythmias.
Question 3
A client with a history of myocardial infarction suddenly
develops severe chest pressure, diaphoresis, and shortness of
breath. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer prescribed sublingual nitroglycerin
C. Ask the client to rate the pain
D. Prepare the client for cardiac catheterization
Correct answer: A. Obtain a 12-lead ECG
Rationale: New severe chest pressure with diaphoresis and
dyspnea requires rapid evaluation for acute coronary syndrome.
A 12-lead ECG should be obtained promptly because it can
identify ischemic changes and determine whether an acute ST-
elevation myocardial infarction may be present. Pain
assessment remains important, and nitroglycerin may be
prescribed when appropriate, but rapid diagnostic assessment is
essential to guide treatment. Cardiac catheterization may
ultimately be necessary but is not the nurse's first independent
action before the immediate cardiac evaluation.
, Question 4
A client receiving a heparin infusion has a platelet count that
decreases substantially from baseline. Which complication
should the nurse suspect?
A. Iron-deficiency anemia
B. Heparin-induced thrombocytopenia
C. Disseminated intravascular coagulation caused by vitamin K
deficiency
D. Pernicious anemia
Correct answer: B. Heparin-induced thrombocytopenia
Rationale: A significant platelet decrease during heparin
therapy raises concern for heparin-induced thrombocytopenia
(HIT), an immune-mediated adverse reaction that paradoxically
increases the risk of thrombosis. The nurse should promptly
notify the provider and anticipate discontinuation of heparin
with evaluation for an alternative anticoagulant. HIT is not
simply a benign decrease in platelets; it can lead to life-
threatening venous or arterial thrombosis. Iron deficiency and
pernicious anemia do not explain an acute platelet decline
associated with heparin exposure.
Question 5
