ATI RN Medical Surgical 2023 (2026
Version) Proctored Exam with NGN 70
Questions and Answers.
Question 1 (Management of Care)
A nurse is caring for a client who is 2 hours postoperative following a transurethral
resection of the prostate (TURP). The client has a three-way indwelling urinary
catheter with continuous bladder irrigation. The nurse notes that the urine output
has decreased significantly, and the client reports bladder spasms and a feeling of
fullness. Which of the following actions should the nurse take first?
A. Increase the IV flow rate
B. Assess the catheter for kinks or obstruction C. Administer a prescribed
antispasmodic medication
D. Notify the provider immediately
Answer: B. Assess the catheter for kinks or obstruction
Rationale: The priority action is to assess for catheter obstruction, which is a
common complication following TURP. Decreased output with bladder spasms and
fullness suggests the irrigation fluid is not draining properly, which could lead to
bladder distention. The nursing process requires assessment before implementing
interventions.
Question 2 (Cardiovascular)
A nurse is assessing a client who has heart failure and is taking furosemide (Lasix)
daily. Which of the following findings should the nurse report to the provider
immediately?
A. Weight gain of 1 kg (2.2 lb) in 24 hours
,B. Dry mucous membranes
C. Heart rate of 68/min
D. Urine output of 75 mL in 4 hours
Answer: A. Weight gain of 1 kg (2.2 lb) in 24 hours
Rationale: A weight gain of 1 kg (2.2 lb) in 24 hours indicates fluid retention of
approximately 1,000 mL, suggesting worsening heart failure. This requires
immediate provider notification for possible medication adjustment. While other
options are important, this represents the most acute change in the client's
condition.
Question 3 (Gastrointestinal)
A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will avoid eating foods that cause gas formation"
B. "I should expect my stoma to be pale and dry"
C. "I will change the entire appliance system daily"
D. "I can use a laxative if I don't have a bowel movement for 2 days"
Answer: A. "I will avoid eating foods that cause gas formation"
Rationale: Clients with new colostomies should avoid gas-forming foods (beans,
cabbage, onions) to prevent discomfort and excessive flatus. A healthy stoma
should be moist and red/pink, not pale and dry. Appliance changes should occur
every 3-7 days, not daily. Laxatives should be avoided without provider guidance
due to altered absorption patterns.
, Question 4 (Respiratory)
A nurse is caring for a client who has a pneumothorax and a chest tube in place
attached to a water seal drainage system. The nurse notes continuous bubbling in
the water seal chamber. Which of the following actions should the nurse take?
A. Clamp the chest tube near the insertion site
B. Check the system for an air leak
C. Increase the suction pressure
D. Milk the tubing to dislodge clots
Answer: B. Check the system for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the system. The nurse should assess all connections and the insertion site.
Intermittent bubbling during exhalation is expected with pneumothorax, but
continuous bubbling suggests a problem that requires investigation.
Question 5 (Endocrine)
A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the
following findings should the nurse expect?
A. Slow, shallow respirations
B. Bradycardia
C. Fruity breath odor
D. Hypertension
Answer: C. Fruity breath odor
Rationale: Fruity breath odor is characteristic of DKA due to acetone accumulation
from fat metabolism. Clients with DKA typically exhibit Kussmaul respirations
(rapid, deep),
Version) Proctored Exam with NGN 70
Questions and Answers.
Question 1 (Management of Care)
A nurse is caring for a client who is 2 hours postoperative following a transurethral
resection of the prostate (TURP). The client has a three-way indwelling urinary
catheter with continuous bladder irrigation. The nurse notes that the urine output
has decreased significantly, and the client reports bladder spasms and a feeling of
fullness. Which of the following actions should the nurse take first?
A. Increase the IV flow rate
B. Assess the catheter for kinks or obstruction C. Administer a prescribed
antispasmodic medication
D. Notify the provider immediately
Answer: B. Assess the catheter for kinks or obstruction
Rationale: The priority action is to assess for catheter obstruction, which is a
common complication following TURP. Decreased output with bladder spasms and
fullness suggests the irrigation fluid is not draining properly, which could lead to
bladder distention. The nursing process requires assessment before implementing
interventions.
Question 2 (Cardiovascular)
A nurse is assessing a client who has heart failure and is taking furosemide (Lasix)
daily. Which of the following findings should the nurse report to the provider
immediately?
A. Weight gain of 1 kg (2.2 lb) in 24 hours
,B. Dry mucous membranes
C. Heart rate of 68/min
D. Urine output of 75 mL in 4 hours
Answer: A. Weight gain of 1 kg (2.2 lb) in 24 hours
Rationale: A weight gain of 1 kg (2.2 lb) in 24 hours indicates fluid retention of
approximately 1,000 mL, suggesting worsening heart failure. This requires
immediate provider notification for possible medication adjustment. While other
options are important, this represents the most acute change in the client's
condition.
Question 3 (Gastrointestinal)
A nurse is providing discharge teaching to a client who has a new colostomy.
Which of the following statements by the client indicates an understanding of the
teaching?
A. "I will avoid eating foods that cause gas formation"
B. "I should expect my stoma to be pale and dry"
C. "I will change the entire appliance system daily"
D. "I can use a laxative if I don't have a bowel movement for 2 days"
Answer: A. "I will avoid eating foods that cause gas formation"
Rationale: Clients with new colostomies should avoid gas-forming foods (beans,
cabbage, onions) to prevent discomfort and excessive flatus. A healthy stoma
should be moist and red/pink, not pale and dry. Appliance changes should occur
every 3-7 days, not daily. Laxatives should be avoided without provider guidance
due to altered absorption patterns.
, Question 4 (Respiratory)
A nurse is caring for a client who has a pneumothorax and a chest tube in place
attached to a water seal drainage system. The nurse notes continuous bubbling in
the water seal chamber. Which of the following actions should the nurse take?
A. Clamp the chest tube near the insertion site
B. Check the system for an air leak
C. Increase the suction pressure
D. Milk the tubing to dislodge clots
Answer: B. Check the system for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the system. The nurse should assess all connections and the insertion site.
Intermittent bubbling during exhalation is expected with pneumothorax, but
continuous bubbling suggests a problem that requires investigation.
Question 5 (Endocrine)
A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the
following findings should the nurse expect?
A. Slow, shallow respirations
B. Bradycardia
C. Fruity breath odor
D. Hypertension
Answer: C. Fruity breath odor
Rationale: Fruity breath odor is characteristic of DKA due to acetone accumulation
from fat metabolism. Clients with DKA typically exhibit Kussmaul respirations
(rapid, deep),
