ATI Med Surg CMS Proctored Exam Questions And
Answers Practice Questions with Solutions Newest |
Already Graded A+
1. A patient with acute pancreatitis develops sudden onset of ecchymosis around the umbilicus and
flank regions. Laboratory results show serum calcium of 7.2 mg/dL (1.8 mmol/L) and triglyceride
level of 1200 mg/dL. Which of the following mechanisms best explains the hypocalcemia in this
context?
A. Increased osteoclastic activity due to parathyroid hormone resistance
B. Saponification of calcium with free fatty acids in the peripancreatic fat
C. Impaired hepatic synthesis of vitamin D-binding protein
D. Renal calcium wasting secondary to acute tubular necrosis
Answer: B
Rationale: In acute pancreatitis, lipase breaks down triglycerides into free fatty acids, which bind
calcium to form calcium soaps (saponification), causing hypocalcemia. Ecchymosis (Cullen and Grey
Turner signs) indicates retroperitoneal hemorrhage. Option A is incorrect because PTH resistance is not
a feature; option C is unrelated; option D is not the primary mechanism.
2. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
dyspnea and JVD. Vital signs: BP 88/50, HR 112, RR 26, SpO2 89% on room air. ECG shows
atrial fibrillation with rapid ventricular response. Which of the following is the priority
intervention?
A. Administer metoprolol 5 mg IV push over 2 minutes
B. Perform synchronized cardioversion at 100 J
C. Administer amiodarone 150 mg IV over 10 minutes
D. Start norepinephrine infusion at 0.5 mcg/min
Answer: D
Rationale: The patient is hypotensive (BP 88/50) with signs of low cardiac output; immediate vasopressor
support (norepinephrine) is needed to maintain perfusion. Metoprolol (A) could worsen hypotension;
synchronized cardioversion (B) is indicated for unstable tachycardia but here the priority is BP support;
amiodarone (C) is an antiarrhythmic but does not address hypotension emergently.
3. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with FiO2 0.8, PEEP 15 cm H2O, plateau pressure 32 cm H2O. Arterial blood gas: pH 7.25,
PaCO2 55, PaO2 60. The provider considers a recruitment maneuver. Which of the following
findings would contraindicate performing this maneuver?
A. Mean arterial pressure 65 mm Hg on norepinephrine
B. Chest tube in place for pneumothorax
Page 1
,C. Body mass index 32 kg/m2
D. Hemoglobin 9.0 g/dL
Answer: B
Rationale: Recruitment maneuvers (sustained high-pressure inflation) increase intrathoracic pressure
and can convert a simple pneumothorax into a tension pneumothorax, especially with a chest tube that
may not be functioning properly. Hypotension on pressors (A) is a relative contraindication but not
absolute; obesity (C) and mild anemia (D) are not contraindications.
4. A patient with cirrhosis and ascites develops acute confusion, asterixis, and a serum ammonia
level of 120 mcg/dL. Which of the following medications is most appropriate to reduce ammonia
production?
A. Neomycin 1 g orally every 6 hours
B. Lactulose 30 mL orally every hour until bowel movement
C. Rifaximin 550 mg orally twice daily
D. Metronidazole 500 mg IV every 8 hours
Answer: B
Rationale: Lactulose is first-line for hepatic encephalopathy; it acidifies the colon, traps ammonium
(NH4+) in stool, and promotes excretion. Neomycin (A) and rifaximin (C) are antibiotics that reduce gut
bacteria but are second-line; lactulose acts more rapidly. Metronidazole (D) is not standard. The goal is
to reduce ammonia absorption, and lactulose achieves this quickly.
5. A patient with type 2 diabetes mellitus is admitted for hyperglycemic hyperosmolar state (HHS).
Labs: serum glucose 850 mg/dL, serum osmolality 350 mOsm/kg, sodium 148 mEq/L, potassium
4.0 mEq/L, and negative serum ketones. Which of the following intravenous fluid regimens is most
appropriate initially?
A. 0.9% normal saline at 15 mL/kg/hour
B. 0.45% normal saline at 250 mL/hour
C. Lactated Ringer's solution at 1 L over 2 hours
D. 5% dextrose in 0.45% normal saline at 100 mL/hour
Answer: A
Rationale: HHS presents with profound dehydration; initial fluid resuscitation is with 0.9% normal saline
(isotonic) at 15-20 mL/kg/hour to restore intravascular volume and correct hyperosmolality.
Half-normal saline (B) is used after volume expansion if sodium is high; lactated Ringer's (C) is less
preferred; dextrose-containing fluids (D) are avoided initially as they raise glucose.
6. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min) is prescribed lisinopril 10 mg
daily. Which of the following laboratory findings would require holding the medication and
notifying the provider?
A. Serum potassium 5.8 mEq/L
B. Serum creatinine 2.5 mg/dL
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.5 g/dL
Page 2
,Answer: A
Rationale: ACE inhibitors can cause hyperkalemia, especially in CKD. A potassium of 5.8 mEq/L is
above 5.5 mEq/L, which is a threshold for holding ACE inhibitors. Creatinine elevation (B) is expected
with ACE inhibition but a rise >30% may require dose adjustment; BUN (C) and hemoglobin (D) are
not contraindications.
7. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor reading of
22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. Which of the following
interventions should the nurse question?
A. Administer mannitol 0.5 g/kg IV
B. Elevate head of bed to 30 degrees
C. Administer propofol infusion for sedation
D. Maintain PaCO2 at 30 mm Hg via mechanical ventilation
Answer: D
Rationale: CPP = MAP - ICP; target CPP is 60-70 mm Hg. Here CPP is 55, indicating inadequate
perfusion. Induced hyperventilation (PaCO2 30) causes cerebral vasoconstriction, which further reduces
cerebral blood flow and CPP. Mannitol (A) reduces ICP; elevating HOB (B) promotes venous drainage;
propofol (C) reduces metabolic demand. Thus D is contraindicated.
8. A patient with a history of venous thromboembolism on warfarin presents with an INR of 6.5
and no bleeding. Which of the following is the most appropriate management?
A. Administer vitamin K 10 mg subcutaneously
B. Administer fresh frozen plasma 2 units
C. Hold warfarin and monitor INR daily
D. Administer prothrombin complex concentrate
Answer: C
Rationale: For an elevated INR >5 but <9 without bleeding, guidelines recommend holding warfarin and
monitoring INR. Vitamin K (A) is indicated if INR >9 or if there is bleeding; FFP (B) and PCC (D) are
reserved for major bleeding or need for rapid reversal. Here, holding and monitoring is safest.
9. A patient with small cell lung cancer develops syndrome of inappropriate antidiuretic hormone
(SIADH). Serum sodium is 120 mEq/L, urine osmolality 600 mOsm/kg, serum osmolality 250
mOsm/kg. Which of the following treatments is most appropriate initially?
A. Administer 3% hypertonic saline at 1 mL/kg/hour
B. Fluid restriction to 800 mL/day
C. Administer demeclocycline 300 mg orally four times daily
D. Administer conivaptan 20 mg IV loading dose
Answer: A
Rationale: Severe hyponatremia (Na <125) with neurological symptoms (though not explicitly stated, the
severity warrants cautious correction). Hypertonic saline (3%) is indicated for severe symptomatic
hyponatremia to raise sodium by 4-6 mEq/L initially. Fluid restriction (B) is for mild/moderate
asymptomatic; demeclocycline (C) and conivaptan (D) are slower and not first-line in this severe case.
Page 3
, 10. A patient with newly diagnosed type 2 diabetes mellitus is started on metformin. Which of the
following mechanisms of action best describes the primary effect of metformin?
A. Stimulates insulin secretion from pancreatic beta cells
B. Increases insulin sensitivity and decreases hepatic gluconeogenesis
C. Delays carbohydrate absorption in the gastrointestinal tract
D. Increases glucose uptake in skeletal muscle via GLUT4 translocation
Answer: B
Rationale: Metformin primarily decreases hepatic glucose production and improves insulin sensitivity,
not secretion. It does not directly stimulate insulin release (sulfonylureas do) nor primarily delay
absorption (acarbose). While it enhances peripheral glucose uptake, the dominant effect is on the liver.
11. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled mechanical
ventilation. Which ventilator setting adjustment is most appropriate to minimize
ventilator-induced lung injury while maintaining adequate oxygenation?
A. Increase positive end-expiratory pressure (PEEP) to 20 cm H2O and reduce tidal volume to 6 mL/kg
predicted body weight
B. Increase tidal volume to 10 mL/kg and decrease respiratory rate to maintain normocapnia
C. Use pressure-controlled ventilation with peak inspiratory pressure of 35 cm H2O and low PEEP
D. Set fraction of inspired oxygen (FiO2) to 1.0 and PEEP to 5 cm H2O
Answer: A
Rationale: In ARDS, lung-protective ventilation using low tidal volumes (6 mL/kg PBW) and moderate to
high PEEP reduces volutrauma and atelectrauma. High tidal volumes (option B) increase barotrauma.
Option C uses high pressure; option D uses low PEEP and high FiO2, risking oxygen toxicity and
alveolar collapse.
12. A patient with chronic heart failure (New York Heart Association class III) is being started on
carvedilol. Which of the following best describes the rationale for initiating beta-blocker therapy in
this population?
A. Immediate improvement in cardiac contractility due to positive inotropic effect
B. Reduction of heart rate and myocardial oxygen demand, leading to reverse remodeling over time
C. Prevention of arrhythmias by blocking sodium channels in the myocardium
D. Dilation of coronary arteries to improve myocardial perfusion
Answer: B
Rationale: Carvedilol is a nonselective beta-blocker with additional alpha-1 blockade. It reduces
sympathetic overactivity, decreases heart rate and contractility, and promotes reverse ventricular
remodeling. It does not have acute positive inotropic effects (option A) nor class I antiarrhythmic (option
C) or direct vasodilatory properties as primary mechanism.
13. A patient undergoing hemodialysis develops muscle cramps and hypotension during the
procedure. Which intervention is most appropriate to prevent recurrence?
A. Increase the ultrafiltration rate to remove more fluid
B. Administer a bolus of hypertonic saline and reduce the ultrafiltration rate
Page 4
Answers Practice Questions with Solutions Newest |
Already Graded A+
1. A patient with acute pancreatitis develops sudden onset of ecchymosis around the umbilicus and
flank regions. Laboratory results show serum calcium of 7.2 mg/dL (1.8 mmol/L) and triglyceride
level of 1200 mg/dL. Which of the following mechanisms best explains the hypocalcemia in this
context?
A. Increased osteoclastic activity due to parathyroid hormone resistance
B. Saponification of calcium with free fatty acids in the peripancreatic fat
C. Impaired hepatic synthesis of vitamin D-binding protein
D. Renal calcium wasting secondary to acute tubular necrosis
Answer: B
Rationale: In acute pancreatitis, lipase breaks down triglycerides into free fatty acids, which bind
calcium to form calcium soaps (saponification), causing hypocalcemia. Ecchymosis (Cullen and Grey
Turner signs) indicates retroperitoneal hemorrhage. Option A is incorrect because PTH resistance is not
a feature; option C is unrelated; option D is not the primary mechanism.
2. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
dyspnea and JVD. Vital signs: BP 88/50, HR 112, RR 26, SpO2 89% on room air. ECG shows
atrial fibrillation with rapid ventricular response. Which of the following is the priority
intervention?
A. Administer metoprolol 5 mg IV push over 2 minutes
B. Perform synchronized cardioversion at 100 J
C. Administer amiodarone 150 mg IV over 10 minutes
D. Start norepinephrine infusion at 0.5 mcg/min
Answer: D
Rationale: The patient is hypotensive (BP 88/50) with signs of low cardiac output; immediate vasopressor
support (norepinephrine) is needed to maintain perfusion. Metoprolol (A) could worsen hypotension;
synchronized cardioversion (B) is indicated for unstable tachycardia but here the priority is BP support;
amiodarone (C) is an antiarrhythmic but does not address hypotension emergently.
3. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with FiO2 0.8, PEEP 15 cm H2O, plateau pressure 32 cm H2O. Arterial blood gas: pH 7.25,
PaCO2 55, PaO2 60. The provider considers a recruitment maneuver. Which of the following
findings would contraindicate performing this maneuver?
A. Mean arterial pressure 65 mm Hg on norepinephrine
B. Chest tube in place for pneumothorax
Page 1
,C. Body mass index 32 kg/m2
D. Hemoglobin 9.0 g/dL
Answer: B
Rationale: Recruitment maneuvers (sustained high-pressure inflation) increase intrathoracic pressure
and can convert a simple pneumothorax into a tension pneumothorax, especially with a chest tube that
may not be functioning properly. Hypotension on pressors (A) is a relative contraindication but not
absolute; obesity (C) and mild anemia (D) are not contraindications.
4. A patient with cirrhosis and ascites develops acute confusion, asterixis, and a serum ammonia
level of 120 mcg/dL. Which of the following medications is most appropriate to reduce ammonia
production?
A. Neomycin 1 g orally every 6 hours
B. Lactulose 30 mL orally every hour until bowel movement
C. Rifaximin 550 mg orally twice daily
D. Metronidazole 500 mg IV every 8 hours
Answer: B
Rationale: Lactulose is first-line for hepatic encephalopathy; it acidifies the colon, traps ammonium
(NH4+) in stool, and promotes excretion. Neomycin (A) and rifaximin (C) are antibiotics that reduce gut
bacteria but are second-line; lactulose acts more rapidly. Metronidazole (D) is not standard. The goal is
to reduce ammonia absorption, and lactulose achieves this quickly.
5. A patient with type 2 diabetes mellitus is admitted for hyperglycemic hyperosmolar state (HHS).
Labs: serum glucose 850 mg/dL, serum osmolality 350 mOsm/kg, sodium 148 mEq/L, potassium
4.0 mEq/L, and negative serum ketones. Which of the following intravenous fluid regimens is most
appropriate initially?
A. 0.9% normal saline at 15 mL/kg/hour
B. 0.45% normal saline at 250 mL/hour
C. Lactated Ringer's solution at 1 L over 2 hours
D. 5% dextrose in 0.45% normal saline at 100 mL/hour
Answer: A
Rationale: HHS presents with profound dehydration; initial fluid resuscitation is with 0.9% normal saline
(isotonic) at 15-20 mL/kg/hour to restore intravascular volume and correct hyperosmolality.
Half-normal saline (B) is used after volume expansion if sodium is high; lactated Ringer's (C) is less
preferred; dextrose-containing fluids (D) are avoided initially as they raise glucose.
6. A patient with chronic kidney disease stage 4 (eGFR 25 mL/min) is prescribed lisinopril 10 mg
daily. Which of the following laboratory findings would require holding the medication and
notifying the provider?
A. Serum potassium 5.8 mEq/L
B. Serum creatinine 2.5 mg/dL
C. Blood urea nitrogen 45 mg/dL
D. Hemoglobin 10.5 g/dL
Page 2
,Answer: A
Rationale: ACE inhibitors can cause hyperkalemia, especially in CKD. A potassium of 5.8 mEq/L is
above 5.5 mEq/L, which is a threshold for holding ACE inhibitors. Creatinine elevation (B) is expected
with ACE inhibition but a rise >30% may require dose adjustment; BUN (C) and hemoglobin (D) are
not contraindications.
7. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor reading of
22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. Which of the following
interventions should the nurse question?
A. Administer mannitol 0.5 g/kg IV
B. Elevate head of bed to 30 degrees
C. Administer propofol infusion for sedation
D. Maintain PaCO2 at 30 mm Hg via mechanical ventilation
Answer: D
Rationale: CPP = MAP - ICP; target CPP is 60-70 mm Hg. Here CPP is 55, indicating inadequate
perfusion. Induced hyperventilation (PaCO2 30) causes cerebral vasoconstriction, which further reduces
cerebral blood flow and CPP. Mannitol (A) reduces ICP; elevating HOB (B) promotes venous drainage;
propofol (C) reduces metabolic demand. Thus D is contraindicated.
8. A patient with a history of venous thromboembolism on warfarin presents with an INR of 6.5
and no bleeding. Which of the following is the most appropriate management?
A. Administer vitamin K 10 mg subcutaneously
B. Administer fresh frozen plasma 2 units
C. Hold warfarin and monitor INR daily
D. Administer prothrombin complex concentrate
Answer: C
Rationale: For an elevated INR >5 but <9 without bleeding, guidelines recommend holding warfarin and
monitoring INR. Vitamin K (A) is indicated if INR >9 or if there is bleeding; FFP (B) and PCC (D) are
reserved for major bleeding or need for rapid reversal. Here, holding and monitoring is safest.
9. A patient with small cell lung cancer develops syndrome of inappropriate antidiuretic hormone
(SIADH). Serum sodium is 120 mEq/L, urine osmolality 600 mOsm/kg, serum osmolality 250
mOsm/kg. Which of the following treatments is most appropriate initially?
A. Administer 3% hypertonic saline at 1 mL/kg/hour
B. Fluid restriction to 800 mL/day
C. Administer demeclocycline 300 mg orally four times daily
D. Administer conivaptan 20 mg IV loading dose
Answer: A
Rationale: Severe hyponatremia (Na <125) with neurological symptoms (though not explicitly stated, the
severity warrants cautious correction). Hypertonic saline (3%) is indicated for severe symptomatic
hyponatremia to raise sodium by 4-6 mEq/L initially. Fluid restriction (B) is for mild/moderate
asymptomatic; demeclocycline (C) and conivaptan (D) are slower and not first-line in this severe case.
Page 3
, 10. A patient with newly diagnosed type 2 diabetes mellitus is started on metformin. Which of the
following mechanisms of action best describes the primary effect of metformin?
A. Stimulates insulin secretion from pancreatic beta cells
B. Increases insulin sensitivity and decreases hepatic gluconeogenesis
C. Delays carbohydrate absorption in the gastrointestinal tract
D. Increases glucose uptake in skeletal muscle via GLUT4 translocation
Answer: B
Rationale: Metformin primarily decreases hepatic glucose production and improves insulin sensitivity,
not secretion. It does not directly stimulate insulin release (sulfonylureas do) nor primarily delay
absorption (acarbose). While it enhances peripheral glucose uptake, the dominant effect is on the liver.
11. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled mechanical
ventilation. Which ventilator setting adjustment is most appropriate to minimize
ventilator-induced lung injury while maintaining adequate oxygenation?
A. Increase positive end-expiratory pressure (PEEP) to 20 cm H2O and reduce tidal volume to 6 mL/kg
predicted body weight
B. Increase tidal volume to 10 mL/kg and decrease respiratory rate to maintain normocapnia
C. Use pressure-controlled ventilation with peak inspiratory pressure of 35 cm H2O and low PEEP
D. Set fraction of inspired oxygen (FiO2) to 1.0 and PEEP to 5 cm H2O
Answer: A
Rationale: In ARDS, lung-protective ventilation using low tidal volumes (6 mL/kg PBW) and moderate to
high PEEP reduces volutrauma and atelectrauma. High tidal volumes (option B) increase barotrauma.
Option C uses high pressure; option D uses low PEEP and high FiO2, risking oxygen toxicity and
alveolar collapse.
12. A patient with chronic heart failure (New York Heart Association class III) is being started on
carvedilol. Which of the following best describes the rationale for initiating beta-blocker therapy in
this population?
A. Immediate improvement in cardiac contractility due to positive inotropic effect
B. Reduction of heart rate and myocardial oxygen demand, leading to reverse remodeling over time
C. Prevention of arrhythmias by blocking sodium channels in the myocardium
D. Dilation of coronary arteries to improve myocardial perfusion
Answer: B
Rationale: Carvedilol is a nonselective beta-blocker with additional alpha-1 blockade. It reduces
sympathetic overactivity, decreases heart rate and contractility, and promotes reverse ventricular
remodeling. It does not have acute positive inotropic effects (option A) nor class I antiarrhythmic (option
C) or direct vasodilatory properties as primary mechanism.
13. A patient undergoing hemodialysis develops muscle cramps and hypotension during the
procedure. Which intervention is most appropriate to prevent recurrence?
A. Increase the ultrafiltration rate to remove more fluid
B. Administer a bolus of hypertonic saline and reduce the ultrafiltration rate
Page 4
