ATI RN Adult Medical Surgical Online Practice
2019 A with NGN| 100% Correct Answers
Cardiovascular Disorders
Q1. A nurse is assessing a client who is 12 hours post-cardiac catheterization. Which of the
following findings requires immediate intervention by the nurse?
A. Report of mild discomfort at the insertion site
B. Hematoma formation at the femoral access site
C. Apical pulse rate of 88 beats per minute
D. Blood pressure of 118/76 mm Hg
Answer: B. Hematoma formation at the femoral access site
Rationale: A hematoma suggests bleeding into the tissue, which can lead to significant blood
loss, retroperitoneal bleeding, or pseudoaneurysm formation. This is a potential
complication requiring immediate assessment and intervention, including applying manual
pressure and notifying the provider. Discomfort is expected; the other vitals are stable.
Q2. A nurse is caring for a client following a myocardial infarction (MI). Which of the
following laboratory values is the most specific indicator of cardiac muscle damage?
A. Creatine kinase (CK-MB)
B. Troponin I
C. C-reactive protein (CRP)
D. Homocysteine
Answer: B. Troponin I
Rationale: Cardiac troponin I and T are highly specific to cardiac muscle and are the gold
standard biomarkers for diagnosing MI. Troponin levels rise within a few hours and remain
elevated for up to 14 days. While CK-MB is cardiac-specific, it is less sensitive and returns to
normal faster than troponin.
Q3. A nurse is providing discharge teaching to a client diagnosed with heart failure (HF).
Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will weigh myself every morning after eating breakfast."
B. "If I gain more than 3 pounds in a day, I will call my doctor."
C. "I should limit my fluid intake to 4 liters a day."
D. "Leg swelling is expected and not a concern if I am walking frequently."
Answer: B. "If I gain more than 3 pounds in a day, I will call my doctor."
,Rationale: Daily weight monitoring is crucial for HF management. A gain of 2-3 lbs in 24
hours or 5 lbs in a week indicates fluid retention and worsening failure, requiring immediate
notification of the provider. Weighing should be done first thing in the morning, after
voiding, before eating.
Q4. A nurse is assessing a client with infective endocarditis. Which of the following
findings is most consistent with this diagnosis?
A. Symmetric joint swelling and morning stiffness
B. Painless, palpable, red lesions on the palms (Osler's nodes)
C. Non-tender, hemorrhagic spots on the fingertips (Janeway lesions)
D. Petechiae on the trunk and conjunctiva
Select all that apply.
Answer: B, C, D
Rationale: All three are classic peripheral stigmata of endocarditis. Osler's nodes are painful,
while Janeway lesions are painless; both are associated with endocarditis. Petechiae are
common on the skin, mucous membranes, and conjunctiva. Symmetric joint swelling
suggests autoimmune conditions like rheumatoid arthritis, not endocarditis.
Q5. A nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which of the
following findings suggests a rupture of the aneurysm?
A. Constipation and urinary retention
B. Severe, sudden low back pain and tearing sensation
C. Bounding pulses in the lower extremities
D. Bradycardia and hypertension
Answer: B. Severe, sudden low back pain and tearing sensation
Rationale: A ruptured AAA is a life-threatening emergency. The classic presentation is
sudden, severe abdominal or back pain radiating to the groin or flanks, often described as
"tearing." This is accompanied by signs of hypovolemic shock (hypotension, tachycardia,
pallor), not hypertension.
Q6. A nurse is administering furosemide to a client with pulmonary edema. Which of the
following assessment findings indicates the medication is having the desired therapeutic
effect?
A. Decreased crackles on lung auscultation
B. Increased central venous pressure (CVP)
C. Decreased urinary output
D. Increased shortness of breath
Answer: A. Decreased crackles on lung auscultation
Rationale: Furosemide is a loop diuretic used to reduce preload by promoting diuresis. The
goal is to reduce pulmonary congestion, which manifests as decreasing crackles (rales),
, improving oxygen saturation, and reducing dyspnea. Diuresis should increase output, not
decrease it.
Q7. A nurse is caring for a client receiving a heparin infusion for deep vein thrombosis
(DVT). The client’s aPTT is 100 seconds (normal range 30-40). Which of the following
actions should the nurse take?
A. Increase the infusion rate to therapeutic levels.
B. Continue the infusion at current rate; this is therapeutic.
C. Stop the infusion and prepare to administer protamine sulfate.
D. Draw a stat INR level.
Answer: C. Stop the infusion and prepare to administer protamine sulfate.
Rationale: For DVT treatment, the goal aPTT is usually 1.5 to 2.5 times the normal control
(approx 60-80 seconds). An aPTT of 100 seconds indicates an excessive anticoagulation
effect, placing the client at high risk for bleeding. The infusion should be stopped, and
protamine sulfate (the antidote for heparin) should be administered as ordered. The INR
monitors warfarin (Coumadin).
Q8. A nurse is providing dietary instructions for a client with hypertension. Which of the
following meal choices indicates an understanding of a low-sodium diet?
A. Ham sandwich with pickles and potato chips
B. Canned vegetable soup with saltine crackers
C. Baked chicken breast with steamed broccoli
D. Soy sauce-marinated steak and white rice
Answer: C. Baked chicken breast with steamed broccoli
Rationale: Fresh or minimally processed foods like baked chicken and steamed vegetables
are naturally low in sodium. Ham, pickles, chips, canned soups, and soy sauce are
notoriously high in sodium additives used for preservation and flavor enhancement.
Q9. A nurse is assessing a client with peripheral arterial disease (PAD). Which of the
following findings is the nurse most likely to observe?
A. Brown discoloration of the ankles
B. Thick, hardened skin with edema
C. Cool extremities with diminished hair growth
D. Foul-smelling drainage from venous stasis ulcers
Answer: C. Cool extremities with diminished hair loss
Rationale: PAD results from atherosclerosis impeding blood flow to the extremities. Chronic
ischemia leads to hair loss, thick toenails, shiny skin, and coolness to the touch. Brown
discoloration and edema are characteristic of chronic venous insufficiency, not arterial
disease.
2019 A with NGN| 100% Correct Answers
Cardiovascular Disorders
Q1. A nurse is assessing a client who is 12 hours post-cardiac catheterization. Which of the
following findings requires immediate intervention by the nurse?
A. Report of mild discomfort at the insertion site
B. Hematoma formation at the femoral access site
C. Apical pulse rate of 88 beats per minute
D. Blood pressure of 118/76 mm Hg
Answer: B. Hematoma formation at the femoral access site
Rationale: A hematoma suggests bleeding into the tissue, which can lead to significant blood
loss, retroperitoneal bleeding, or pseudoaneurysm formation. This is a potential
complication requiring immediate assessment and intervention, including applying manual
pressure and notifying the provider. Discomfort is expected; the other vitals are stable.
Q2. A nurse is caring for a client following a myocardial infarction (MI). Which of the
following laboratory values is the most specific indicator of cardiac muscle damage?
A. Creatine kinase (CK-MB)
B. Troponin I
C. C-reactive protein (CRP)
D. Homocysteine
Answer: B. Troponin I
Rationale: Cardiac troponin I and T are highly specific to cardiac muscle and are the gold
standard biomarkers for diagnosing MI. Troponin levels rise within a few hours and remain
elevated for up to 14 days. While CK-MB is cardiac-specific, it is less sensitive and returns to
normal faster than troponin.
Q3. A nurse is providing discharge teaching to a client diagnosed with heart failure (HF).
Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will weigh myself every morning after eating breakfast."
B. "If I gain more than 3 pounds in a day, I will call my doctor."
C. "I should limit my fluid intake to 4 liters a day."
D. "Leg swelling is expected and not a concern if I am walking frequently."
Answer: B. "If I gain more than 3 pounds in a day, I will call my doctor."
,Rationale: Daily weight monitoring is crucial for HF management. A gain of 2-3 lbs in 24
hours or 5 lbs in a week indicates fluid retention and worsening failure, requiring immediate
notification of the provider. Weighing should be done first thing in the morning, after
voiding, before eating.
Q4. A nurse is assessing a client with infective endocarditis. Which of the following
findings is most consistent with this diagnosis?
A. Symmetric joint swelling and morning stiffness
B. Painless, palpable, red lesions on the palms (Osler's nodes)
C. Non-tender, hemorrhagic spots on the fingertips (Janeway lesions)
D. Petechiae on the trunk and conjunctiva
Select all that apply.
Answer: B, C, D
Rationale: All three are classic peripheral stigmata of endocarditis. Osler's nodes are painful,
while Janeway lesions are painless; both are associated with endocarditis. Petechiae are
common on the skin, mucous membranes, and conjunctiva. Symmetric joint swelling
suggests autoimmune conditions like rheumatoid arthritis, not endocarditis.
Q5. A nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which of the
following findings suggests a rupture of the aneurysm?
A. Constipation and urinary retention
B. Severe, sudden low back pain and tearing sensation
C. Bounding pulses in the lower extremities
D. Bradycardia and hypertension
Answer: B. Severe, sudden low back pain and tearing sensation
Rationale: A ruptured AAA is a life-threatening emergency. The classic presentation is
sudden, severe abdominal or back pain radiating to the groin or flanks, often described as
"tearing." This is accompanied by signs of hypovolemic shock (hypotension, tachycardia,
pallor), not hypertension.
Q6. A nurse is administering furosemide to a client with pulmonary edema. Which of the
following assessment findings indicates the medication is having the desired therapeutic
effect?
A. Decreased crackles on lung auscultation
B. Increased central venous pressure (CVP)
C. Decreased urinary output
D. Increased shortness of breath
Answer: A. Decreased crackles on lung auscultation
Rationale: Furosemide is a loop diuretic used to reduce preload by promoting diuresis. The
goal is to reduce pulmonary congestion, which manifests as decreasing crackles (rales),
, improving oxygen saturation, and reducing dyspnea. Diuresis should increase output, not
decrease it.
Q7. A nurse is caring for a client receiving a heparin infusion for deep vein thrombosis
(DVT). The client’s aPTT is 100 seconds (normal range 30-40). Which of the following
actions should the nurse take?
A. Increase the infusion rate to therapeutic levels.
B. Continue the infusion at current rate; this is therapeutic.
C. Stop the infusion and prepare to administer protamine sulfate.
D. Draw a stat INR level.
Answer: C. Stop the infusion and prepare to administer protamine sulfate.
Rationale: For DVT treatment, the goal aPTT is usually 1.5 to 2.5 times the normal control
(approx 60-80 seconds). An aPTT of 100 seconds indicates an excessive anticoagulation
effect, placing the client at high risk for bleeding. The infusion should be stopped, and
protamine sulfate (the antidote for heparin) should be administered as ordered. The INR
monitors warfarin (Coumadin).
Q8. A nurse is providing dietary instructions for a client with hypertension. Which of the
following meal choices indicates an understanding of a low-sodium diet?
A. Ham sandwich with pickles and potato chips
B. Canned vegetable soup with saltine crackers
C. Baked chicken breast with steamed broccoli
D. Soy sauce-marinated steak and white rice
Answer: C. Baked chicken breast with steamed broccoli
Rationale: Fresh or minimally processed foods like baked chicken and steamed vegetables
are naturally low in sodium. Ham, pickles, chips, canned soups, and soy sauce are
notoriously high in sodium additives used for preservation and flavor enhancement.
Q9. A nurse is assessing a client with peripheral arterial disease (PAD). Which of the
following findings is the nurse most likely to observe?
A. Brown discoloration of the ankles
B. Thick, hardened skin with edema
C. Cool extremities with diminished hair growth
D. Foul-smelling drainage from venous stasis ulcers
Answer: C. Cool extremities with diminished hair loss
Rationale: PAD results from atherosclerosis impeding blood flow to the extremities. Chronic
ischemia leads to hair loss, thick toenails, shiny skin, and coolness to the touch. Brown
discoloration and edema are characteristic of chronic venous insufficiency, not arterial
disease.
