ATI RN Comprehensive Predictor Review Advanced Prep: Master Adult
Medical-Surgical & Critical Care Nursing Practice Questions
Subject: Nursing / Registered Nurse (RN) Comprehensive Review
Subtopic: Fluid and Electrolyte Management, Advanced Cardiac Care, and
Critical Care Nursing
Question 1: A client with acute decompensated heart failure is receiving a continuous
intravenous infusion of nitroprusside sodium at 3 mcg/kg/min. The nurse notes the client is
becoming progressively confused, agitated, and complains of a metallic taste in the mouth. The
client's oxygen saturation is 94% on a non-rebreather mask, but the arterial blood gas (ABG)
shows a profound metabolic acidosis with a normal PaO2. Which of the following is the priority
nursing action?
A) Increase the rate of the nitroprusside infusion to reduce cardiac workload and improve
cerebral perfusion.
B) Administer the prescribed antidote, sodium thiosulfate, and prepare to discontinue the
nitroprusside infusion.
C) Place the client in a prone position to optimize ventilation-perfusion matching.
D) Request an immediate prescription for an intravenous loop diuretic to treat acute fluid volume
overload.
Correct Answer: B) Administer the prescribed antidote, sodium thiosulfate, and prepare to
discontinue the nitroprusside infusion.
Explanation: Nitroprusside sodium is a potent vasodilator metabolized into thiocyanate and
cyanide. Prolonged infusions, high doses (>2 mcg/kg/min), or renal/hepatic impairment increase
the risk of cyanide toxicity. Clinical manifestations include altered mental status, agitation, a
metallic taste, and cellular hypoxia leading to anaerobic metabolism and lactic (metabolic)
acidosis despite normal arterial oxygen tension. Sodium thiosulfate acts as a sulfur donor to
facilitate the conversion of cyanide into thiocyanate, which can then be renally excreted.
Increasing the infusion rate would worsen the toxicity. Prone positioning is indicated for ARDS,
not toxic metabolic encephalopathy. Diuretics do not address the cellular toxicity.
Question 2: A nurse in the intensive care unit is caring for a client who sustained a severe
traumatic brain injury and is receiving mechanical ventilation. The client's hourly urine output
has abruptly increased to 450 mL/hr over the past two hours. The current laboratory results
reveal a serum sodium level of 156 mEq/L and a urine specific gravity of 1.002. Which of the
following provider prescriptions should the nurse anticipate executing first?
A) Intravenous administration of 3% hypertonic saline at 50 mL/hr.
,B) Intravenous administration of desmopressin (DDAVP) and initiation of 0.45% normal saline.
C) Strict fluid restriction to less than 800 mL per 24 hours.
D) Intravenous bolus of 20% mannitol over 30 minutes.
Correct Answer: B) Intravenous administration of desmopressin (DDAVP) and initiation of
0.45% normal saline.
Explanation: The client's clinical presentation—massive polyuria, profound hypernatremia
(serum sodium >145 mEq/L), and extremely dilute urine (specific gravity <1.005)—following a
traumatic brain injury is highly indicative of Central Diabetes Insipidus (DI) caused by a
deficiency in antidiuretic hormone (ADH) secretion. Desmopressin is a synthetic analogue of
ADH that will increase water reabsorption in the renal collecting ducts. Hypotonic fluids (0.45%
NS) are used to safely replace the free water deficit. Administering 3% hypertonic saline or
mannitol would profoundly worsen the hypernatremia and cellular dehydration. Fluid restriction
is the treatment choice for SIADH, which presents with low urine output and hyponatremia.
Question 3: A client with a history of severe chronic obstructive pulmonary disease (COPD) is
admitted to the emergency department in acute respiratory distress. The client's initial arterial
blood gas (ABG) on room air shows: pH 7.22, PaCO2 68 mm Hg, HCO3- 26 mEq/L, and PaO2
51 mm Hg. How should the nurse accurately interpret this acid-base imbalance?
A) Fully compensated respiratory acidosis with severe hypoxemia.
B) Uncompensated metabolic acidosis with mild hypoxemia.
C) Uncompensated respiratory acidosis with severe hypoxemia.
D) Partially compensated metabolic alkalosis with normal oxygenation.
Correct Answer: C) Uncompensated respiratory acidosis with severe hypoxemia.
Explanation: The pH of 7.22 is below the normal range (7.35–7.45), indicating acidosis. The
PaCO2 of 68 mm Hg is significantly elevated above the normal range (35–45 mm Hg), matching
the directional shift of the pH, which confirms a respiratory origin. The HCO3- of 26 mEq/L falls
within the normal range (22–26 mEq/L), demonstrating that the kidneys have not yet had
sufficient time to retain bicarbonate to compensate for the acute respiratory retention of carbon
dioxide. Therefore, it is uncompensated. A PaO2 of 51 mm Hg indicates severe hypoxemia
(normal is 80–100 mm Hg).
Question 4: The nurse is reviewing the electrocardiogram (ECG) of a client admitted with an
acute anterolateral myocardial infarction. The monitor suddenly displays a regular, wide-
complex rhythm at a rate of 162 beats/minute. The client is awake, responsive, and has a
palpable carotid pulse, but their blood pressure has dropped to 84/52 mm Hg. Which of the
following is the most appropriate immediate nursing intervention?
,A) Initiate immediate synchronized cardioversion starting at the recommended energy level.
B) Administer an intravenous bolus of adenosine 6 mg rapidly over 1 to 2 seconds.
C) Begin high-quality chest compressions and prepare to deliver an unsynchronized shock at 200
joules.
D) Instruct the client to perform a Valsalva maneuver or perform a carotid sinus massage.
Correct Answer: A) Initiate immediate synchronized cardioversion starting at the
recommended energy level.
Explanation: The client is experiencing monomorphic ventricular tachycardia with a pulse,
accompanied by signs of hemodynamic instability (hypotension, blood pressure 84/52 mm Hg).
According to Advanced Cardiovascular Life Support (ACLS) guidelines, unstable ventricular
tachycardia with a pulse requires immediate synchronized cardioversion to disrupt the re-
entrant circuit and restore a perfusing rhythm. Unsynchronized defibrillation and chest
compressions are reserved for pulseless ventricular tachycardia or ventricular fibrillation.
Adenosine and vagal maneuvers are utilized for narrow-complex supraventricular tachycardias,
not wide-complex ventricular rhythms with hemodynamic collapse.
Question 5: A client is admitted with severe acute pancreatitis. The nurse is reviewing the client's
morning laboratory results and notes a total serum calcium level of 6.8 mg/dL. Which of the
following physical assessment findings should the nurse expect to elicit based on this laboratory
value?
A) Muscle flaccidity, hyporeflexia, and a shortened QT interval on the ECG.
B) Severe constipation, bone pain, and depressed deep tendon reflexes.
C) Carpopedal spasm induced by inflating a blood pressure cuff above the systolic pressure.
D) Decreased bowel sounds, abdominal distension, and prominent U waves on the ECG.
Correct Answer: C) Carpopedal spasm induced by inflating a blood pressure cuff above the
systolic pressure.
Explanation: A total serum calcium level of 6.8 mg/dL indicates hypocalcemia (normal range is
9.0–10.5 mg/dL). In acute pancreatitis, hypocalcemia occurs due to enzymatic fat necrosis,
where free fatty acids bind with calcium ions (saponification). Hypocalcemia increases
neuromuscular excitability. Inflating a blood pressure cuff above the systolic pressure for 3
minutes to induce a carpopedal spasm is known as Trousseau's sign, a classic manifestation of
hypocalcemia. Muscle flaccidity, constipation, and hyporeflexia are associated with
hypercalcemia. U waves are a characteristic sign of hypokalemia, not hypocalcemia.
, Question 6: A nurse is caring for a client who is in the compensatory stage of hypovolemic shock
following a severe gastrointestinal hemorrhage. Which of the following clinical indicators should
the nurse recognize as a manifestation of the body's compensatory mechanisms?
A) A narrowing pulse pressure accompanied by peripheral vasoconstriction and cool, pale skin.
B) An elevated urine output exceeding 60 mL/hour due to increased renal perfusion.
C) Metabolic alkalosis resulting from deep, rapid Kussmaul respirations.
D) Bradycardia and a significant decrease in the respiratory rate.
Correct Answer: A) A narrowing pulse pressure accompanied by peripheral
vasoconstriction and cool, pale skin.
Explanation: During the compensatory stage of hypovolemic shock, a decrease in circulating
blood volume triggers the sympathetic nervous system (SNS) to release epinephrine and
norepinephrine. This response leads to systemic peripheral vasoconstriction, shunting blood to
vital organs and resulting in cool, pale skin. The diastolic blood pressure rises due to increased
systemic vascular resistance, which narrows the pulse pressure. Urine output decreases (not
increases) due to the activation of the renin-angiotensin-aldosterone system (RAAS) to conserve
water. Tissue perfusion deficits cause anaerobic metabolism, leading to metabolic acidosis, not
alkalosis. Tachycardia and tachypnea occur to maintain cardiac output and oxygenation.
Question 7: The nurse is preparing to administer an intravenous loading dose of digoxin 0.5 mg
to a client with chronic atrial fibrillation. Which of the following laboratory values or clinical
findings requires the nurse to hold the medication and notify the healthcare provider
immediately?
A) Serum potassium level of 3.1 mEq/L.
B) Serum digoxin level of 0.6 ng/mL.
C) Apical pulse rate of 88 beats/minute.
D) Serum calcium level of 9.2 mg/dL.
Correct Answer: A) Serum potassium level of 3.1 mEq/L.
Explanation: Hypokalemia (potassium level <3.5 mEq/L) significantly increases the risk of
digoxin toxicity. Digoxin binds to the sodium-potassium ATPase pump on cardiac membranes by
competing with potassium ions. When potassium levels are low, digoxin binds more easily and
firmly, magnifying its therapeutic and toxic effects even if the serum digoxin level itself is within
the therapeutic range (0.5–2.0 ng/mL). An apical pulse of 88 beats/minute is safe for
administration (typically held if <60 beats/minute). A calcium level of 9.2 mg/dL is within the
normal range.
Medical-Surgical & Critical Care Nursing Practice Questions
Subject: Nursing / Registered Nurse (RN) Comprehensive Review
Subtopic: Fluid and Electrolyte Management, Advanced Cardiac Care, and
Critical Care Nursing
Question 1: A client with acute decompensated heart failure is receiving a continuous
intravenous infusion of nitroprusside sodium at 3 mcg/kg/min. The nurse notes the client is
becoming progressively confused, agitated, and complains of a metallic taste in the mouth. The
client's oxygen saturation is 94% on a non-rebreather mask, but the arterial blood gas (ABG)
shows a profound metabolic acidosis with a normal PaO2. Which of the following is the priority
nursing action?
A) Increase the rate of the nitroprusside infusion to reduce cardiac workload and improve
cerebral perfusion.
B) Administer the prescribed antidote, sodium thiosulfate, and prepare to discontinue the
nitroprusside infusion.
C) Place the client in a prone position to optimize ventilation-perfusion matching.
D) Request an immediate prescription for an intravenous loop diuretic to treat acute fluid volume
overload.
Correct Answer: B) Administer the prescribed antidote, sodium thiosulfate, and prepare to
discontinue the nitroprusside infusion.
Explanation: Nitroprusside sodium is a potent vasodilator metabolized into thiocyanate and
cyanide. Prolonged infusions, high doses (>2 mcg/kg/min), or renal/hepatic impairment increase
the risk of cyanide toxicity. Clinical manifestations include altered mental status, agitation, a
metallic taste, and cellular hypoxia leading to anaerobic metabolism and lactic (metabolic)
acidosis despite normal arterial oxygen tension. Sodium thiosulfate acts as a sulfur donor to
facilitate the conversion of cyanide into thiocyanate, which can then be renally excreted.
Increasing the infusion rate would worsen the toxicity. Prone positioning is indicated for ARDS,
not toxic metabolic encephalopathy. Diuretics do not address the cellular toxicity.
Question 2: A nurse in the intensive care unit is caring for a client who sustained a severe
traumatic brain injury and is receiving mechanical ventilation. The client's hourly urine output
has abruptly increased to 450 mL/hr over the past two hours. The current laboratory results
reveal a serum sodium level of 156 mEq/L and a urine specific gravity of 1.002. Which of the
following provider prescriptions should the nurse anticipate executing first?
A) Intravenous administration of 3% hypertonic saline at 50 mL/hr.
,B) Intravenous administration of desmopressin (DDAVP) and initiation of 0.45% normal saline.
C) Strict fluid restriction to less than 800 mL per 24 hours.
D) Intravenous bolus of 20% mannitol over 30 minutes.
Correct Answer: B) Intravenous administration of desmopressin (DDAVP) and initiation of
0.45% normal saline.
Explanation: The client's clinical presentation—massive polyuria, profound hypernatremia
(serum sodium >145 mEq/L), and extremely dilute urine (specific gravity <1.005)—following a
traumatic brain injury is highly indicative of Central Diabetes Insipidus (DI) caused by a
deficiency in antidiuretic hormone (ADH) secretion. Desmopressin is a synthetic analogue of
ADH that will increase water reabsorption in the renal collecting ducts. Hypotonic fluids (0.45%
NS) are used to safely replace the free water deficit. Administering 3% hypertonic saline or
mannitol would profoundly worsen the hypernatremia and cellular dehydration. Fluid restriction
is the treatment choice for SIADH, which presents with low urine output and hyponatremia.
Question 3: A client with a history of severe chronic obstructive pulmonary disease (COPD) is
admitted to the emergency department in acute respiratory distress. The client's initial arterial
blood gas (ABG) on room air shows: pH 7.22, PaCO2 68 mm Hg, HCO3- 26 mEq/L, and PaO2
51 mm Hg. How should the nurse accurately interpret this acid-base imbalance?
A) Fully compensated respiratory acidosis with severe hypoxemia.
B) Uncompensated metabolic acidosis with mild hypoxemia.
C) Uncompensated respiratory acidosis with severe hypoxemia.
D) Partially compensated metabolic alkalosis with normal oxygenation.
Correct Answer: C) Uncompensated respiratory acidosis with severe hypoxemia.
Explanation: The pH of 7.22 is below the normal range (7.35–7.45), indicating acidosis. The
PaCO2 of 68 mm Hg is significantly elevated above the normal range (35–45 mm Hg), matching
the directional shift of the pH, which confirms a respiratory origin. The HCO3- of 26 mEq/L falls
within the normal range (22–26 mEq/L), demonstrating that the kidneys have not yet had
sufficient time to retain bicarbonate to compensate for the acute respiratory retention of carbon
dioxide. Therefore, it is uncompensated. A PaO2 of 51 mm Hg indicates severe hypoxemia
(normal is 80–100 mm Hg).
Question 4: The nurse is reviewing the electrocardiogram (ECG) of a client admitted with an
acute anterolateral myocardial infarction. The monitor suddenly displays a regular, wide-
complex rhythm at a rate of 162 beats/minute. The client is awake, responsive, and has a
palpable carotid pulse, but their blood pressure has dropped to 84/52 mm Hg. Which of the
following is the most appropriate immediate nursing intervention?
,A) Initiate immediate synchronized cardioversion starting at the recommended energy level.
B) Administer an intravenous bolus of adenosine 6 mg rapidly over 1 to 2 seconds.
C) Begin high-quality chest compressions and prepare to deliver an unsynchronized shock at 200
joules.
D) Instruct the client to perform a Valsalva maneuver or perform a carotid sinus massage.
Correct Answer: A) Initiate immediate synchronized cardioversion starting at the
recommended energy level.
Explanation: The client is experiencing monomorphic ventricular tachycardia with a pulse,
accompanied by signs of hemodynamic instability (hypotension, blood pressure 84/52 mm Hg).
According to Advanced Cardiovascular Life Support (ACLS) guidelines, unstable ventricular
tachycardia with a pulse requires immediate synchronized cardioversion to disrupt the re-
entrant circuit and restore a perfusing rhythm. Unsynchronized defibrillation and chest
compressions are reserved for pulseless ventricular tachycardia or ventricular fibrillation.
Adenosine and vagal maneuvers are utilized for narrow-complex supraventricular tachycardias,
not wide-complex ventricular rhythms with hemodynamic collapse.
Question 5: A client is admitted with severe acute pancreatitis. The nurse is reviewing the client's
morning laboratory results and notes a total serum calcium level of 6.8 mg/dL. Which of the
following physical assessment findings should the nurse expect to elicit based on this laboratory
value?
A) Muscle flaccidity, hyporeflexia, and a shortened QT interval on the ECG.
B) Severe constipation, bone pain, and depressed deep tendon reflexes.
C) Carpopedal spasm induced by inflating a blood pressure cuff above the systolic pressure.
D) Decreased bowel sounds, abdominal distension, and prominent U waves on the ECG.
Correct Answer: C) Carpopedal spasm induced by inflating a blood pressure cuff above the
systolic pressure.
Explanation: A total serum calcium level of 6.8 mg/dL indicates hypocalcemia (normal range is
9.0–10.5 mg/dL). In acute pancreatitis, hypocalcemia occurs due to enzymatic fat necrosis,
where free fatty acids bind with calcium ions (saponification). Hypocalcemia increases
neuromuscular excitability. Inflating a blood pressure cuff above the systolic pressure for 3
minutes to induce a carpopedal spasm is known as Trousseau's sign, a classic manifestation of
hypocalcemia. Muscle flaccidity, constipation, and hyporeflexia are associated with
hypercalcemia. U waves are a characteristic sign of hypokalemia, not hypocalcemia.
, Question 6: A nurse is caring for a client who is in the compensatory stage of hypovolemic shock
following a severe gastrointestinal hemorrhage. Which of the following clinical indicators should
the nurse recognize as a manifestation of the body's compensatory mechanisms?
A) A narrowing pulse pressure accompanied by peripheral vasoconstriction and cool, pale skin.
B) An elevated urine output exceeding 60 mL/hour due to increased renal perfusion.
C) Metabolic alkalosis resulting from deep, rapid Kussmaul respirations.
D) Bradycardia and a significant decrease in the respiratory rate.
Correct Answer: A) A narrowing pulse pressure accompanied by peripheral
vasoconstriction and cool, pale skin.
Explanation: During the compensatory stage of hypovolemic shock, a decrease in circulating
blood volume triggers the sympathetic nervous system (SNS) to release epinephrine and
norepinephrine. This response leads to systemic peripheral vasoconstriction, shunting blood to
vital organs and resulting in cool, pale skin. The diastolic blood pressure rises due to increased
systemic vascular resistance, which narrows the pulse pressure. Urine output decreases (not
increases) due to the activation of the renin-angiotensin-aldosterone system (RAAS) to conserve
water. Tissue perfusion deficits cause anaerobic metabolism, leading to metabolic acidosis, not
alkalosis. Tachycardia and tachypnea occur to maintain cardiac output and oxygenation.
Question 7: The nurse is preparing to administer an intravenous loading dose of digoxin 0.5 mg
to a client with chronic atrial fibrillation. Which of the following laboratory values or clinical
findings requires the nurse to hold the medication and notify the healthcare provider
immediately?
A) Serum potassium level of 3.1 mEq/L.
B) Serum digoxin level of 0.6 ng/mL.
C) Apical pulse rate of 88 beats/minute.
D) Serum calcium level of 9.2 mg/dL.
Correct Answer: A) Serum potassium level of 3.1 mEq/L.
Explanation: Hypokalemia (potassium level <3.5 mEq/L) significantly increases the risk of
digoxin toxicity. Digoxin binds to the sodium-potassium ATPase pump on cardiac membranes by
competing with potassium ions. When potassium levels are low, digoxin binds more easily and
firmly, magnifying its therapeutic and toxic effects even if the serum digoxin level itself is within
the therapeutic range (0.5–2.0 ng/mL). An apical pulse of 88 beats/minute is safe for
administration (typically held if <60 beats/minute). A calcium level of 9.2 mg/dL is within the
normal range.
