ATI PN MEDICAL SURGICAL CMS FINAL ACTUAL EXAM
2026/2027 | NGN Next Gen NCLEX Format | Clinical
Judgment Measurement Model | Complete Q&A with
Detailed Answer Key | Pass Guaranteed - A+ Graded
SECTION 1: NGN UNFOLDING CASE STUDY #1 — CARDIOVASCULAR &
RESPIRATORY INTEGRATION (Heart Failure, COPD, Pneumonia)
Patient Scenario: Mr. Johnson, 72 years old, arrives at the emergency department via
ambulance with worsening dyspnea over the past 3 days. History includes chronic
HFrEF (EF 35%), COPD GOLD Stage 3, hypertension, and type 2 diabetes. Home
medications: furosemide 40 mg PO daily, lisinopril 10 mg PO daily, metoprolol
succinate 50 mg PO daily, albuterol/ipratropium nebulizer PRN,
fluticasone/salmeterol 250/50 mcg inhaler BID, tiotropium 18 mcg inhaler daily,
aspirin 81 mg daily.
Vital Signs & Assessment on Arrival: BP 168/98, HR 112 (irregularly irregular), RR 28,
SpO2 86% on 2L nasal cannula (baseline 88-90% on 2L at home), T 99.1°F. Patient is
alert but anxious, unable to speak in full sentences. Physical exam: +3 pitting edema
bilateral lower extremities, JVD distended at 45°, crackles 2/3 up bilateral lung bases,
wheezing bilaterally, prolonged expiration, intercostal retractions, nasal flaring, using
accessory muscles. Weight gain of +6 lbs in 5 days per family report. Family states he
has been sleeping upright in recliner with 3 pillows for past week and was awakened
gasping for air last night.
Diagnostic Results: ABG: pH 7.32, PaCO2 58, PaO2 55, HCO3 30, BNP 1200 pg/mL
(normal <100), Chest X-ray: cardiomegaly, bilateral pulmonary vascular congestion,
small bilateral pleural effusions, no lobar consolidation. CBC: WBC 11,500, Hgb 10.8,
Hct 33%. BMP: Na+ 138, K+ 3.2, Cl- 102, CO2 32, BUN 38, Cr 1.8 (baseline 1.2),
Glucose 142.
Q1. (Recognize Cues — Multiple Choice) Which cluster of assessment findings best
indicates acute decompensated heart failure with superimposed COPD exacerbation?
,A. Wheezing, prolonged expiration, and nasal flaring only
B. Crackles, JVD, +3 edema, orthopnea, elevated BNP, and weight gain
C. Fever 99.1°F, WBC 11,500, and glucose 142
D. HR 112 irregularly irregular and Hgb 10.8 only
Correct Answer: B. Crackles, JVD, +3 edema, orthopnea, elevated BNP, and weight
gain [CORRECT]
Rationale: This cluster represents systemic and pulmonary congestion (JVD, edema,
crackles, orthopnea, weight gain, elevated BNP) combined with COPD signs
(wheezing, prolonged expiration, accessory muscle use). CJMM Layer: Recognize
Cues.
Q2. (Recognize Cues — Multiple Response SATA) Select all assessment findings that
are ABNORMAL for this patient and require immediate nursing attention.
A. SpO2 86% on 2L nasal cannula
B. pH 7.32
C. PaCO2 58
D. HCO3 30
E. BNP 1200 pg/mL
F. K+ 3.2
G. RR 28
H. +3 pitting edema bilateral lower extremities
Correct Answer: A, B, C, E, F, G, H [CORRECT]
Rationale: All are abnormal except D (HCO3 30 is elevated indicating metabolic
compensation, which is an expected compensatory response rather than an acute
abnormality requiring immediate intervention) and the normal-ish glucose/WBC.
CJMM Layer: Recognize Cues.
Q3. (Analyze Cues — Multiple Choice) The nurse analyzes the ABG results. Which
interpretation is most accurate?
,A. Metabolic alkalosis with respiratory compensation
B. Respiratory acidosis with metabolic compensation (acute on chronic)
C. Metabolic acidosis with respiratory compensation
D. Respiratory alkalosis with metabolic compensation
Correct Answer: B. Respiratory acidosis with metabolic compensation (acute on
chronic) [CORRECT]
Rationale: pH 7.32 (acidemia), PaCO2 58 (respiratory acidosis), HCO3 30 (metabolic
compensation). Given COPD baseline, this represents acute on chronic respiratory
acidosis. CJMM Layer: Analyze Cues.
Q4. (Analyze Cues — Multiple Choice) The nurse differentiates between HF
exacerbation and COPD exacerbation. Which finding most specifically supports HF
exacerbation as the primary driver of decompensation?
A. Wheezing and prolonged expiration
B. JVD, +3 edema, and elevated BNP
C. PaCO2 58 and pH 7.32
D. Accessory muscle use and nasal flaring
Correct Answer: B. JVD, +3 edema, and elevated BNP [CORRECT]
Rationale: JVD, peripheral edema, and markedly elevated BNP are specific to fluid
overload and ventricular stretch in heart failure. Wheezing and hypercapnia are more
specific to COPD. CJMM Layer: Analyze Cues.
Q5. (Analyze Cues — Multiple Choice) Which complication is this patient at highest
risk for if the current hypercapnic respiratory failure is not promptly addressed?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Acute respiratory acidosis leading to altered mental status and respiratory arrest
D. Chronic compensated respiratory alkalosis
, Correct Answer: C. Acute respiratory acidosis leading to altered mental status and
respiratory arrest [CORRECT]
Rationale: Progressive hypercapnia (PaCO2 >60-70) causes CO2 narcosis, leading to
confusion, somnolence, asterixis, and potential respiratory arrest. CJMM Layer:
Analyze Cues.
Q6. (Prioritize Hypotheses — Multiple Choice) Based on the assessment and
diagnostic data, which condition should the nurse prioritize as the most likely and
most dangerous hypothesis?
A. Community-acquired pneumonia
B. Acute decompensated heart failure with superimposed COPD exacerbation
C. Pulmonary embolism
D. Acute coronary syndrome
Correct Answer: B. Acute decompensated heart failure with superimposed COPD
exacerbation [CORRECT]
Rationale: The combination of volume overload signs (JVD, edema, BNP elevation,
weight gain), pulmonary congestion (crackles, orthopnea, PND), and COPD signs
(wheezing, hypercapnia, accessory muscle use) best fits this dual diagnosis.
Pneumonia would show lobar consolidation; PE would show sudden dyspnea with
clear chest X-ray and possible D-dimer elevation. CJMM Layer: Prioritize Hypotheses.
Q7. (Prioritize Hypotheses — Multiple Choice) Which "can't miss" diagnosis must
the nurse consider and rule out given the patient's presentation?
A. Stable angina
B. Pulmonary embolism
C. Osteoarthritis
D. Hypothyroidism
Correct Answer: B. Pulmonary embolism [CORRECT]
2026/2027 | NGN Next Gen NCLEX Format | Clinical
Judgment Measurement Model | Complete Q&A with
Detailed Answer Key | Pass Guaranteed - A+ Graded
SECTION 1: NGN UNFOLDING CASE STUDY #1 — CARDIOVASCULAR &
RESPIRATORY INTEGRATION (Heart Failure, COPD, Pneumonia)
Patient Scenario: Mr. Johnson, 72 years old, arrives at the emergency department via
ambulance with worsening dyspnea over the past 3 days. History includes chronic
HFrEF (EF 35%), COPD GOLD Stage 3, hypertension, and type 2 diabetes. Home
medications: furosemide 40 mg PO daily, lisinopril 10 mg PO daily, metoprolol
succinate 50 mg PO daily, albuterol/ipratropium nebulizer PRN,
fluticasone/salmeterol 250/50 mcg inhaler BID, tiotropium 18 mcg inhaler daily,
aspirin 81 mg daily.
Vital Signs & Assessment on Arrival: BP 168/98, HR 112 (irregularly irregular), RR 28,
SpO2 86% on 2L nasal cannula (baseline 88-90% on 2L at home), T 99.1°F. Patient is
alert but anxious, unable to speak in full sentences. Physical exam: +3 pitting edema
bilateral lower extremities, JVD distended at 45°, crackles 2/3 up bilateral lung bases,
wheezing bilaterally, prolonged expiration, intercostal retractions, nasal flaring, using
accessory muscles. Weight gain of +6 lbs in 5 days per family report. Family states he
has been sleeping upright in recliner with 3 pillows for past week and was awakened
gasping for air last night.
Diagnostic Results: ABG: pH 7.32, PaCO2 58, PaO2 55, HCO3 30, BNP 1200 pg/mL
(normal <100), Chest X-ray: cardiomegaly, bilateral pulmonary vascular congestion,
small bilateral pleural effusions, no lobar consolidation. CBC: WBC 11,500, Hgb 10.8,
Hct 33%. BMP: Na+ 138, K+ 3.2, Cl- 102, CO2 32, BUN 38, Cr 1.8 (baseline 1.2),
Glucose 142.
Q1. (Recognize Cues — Multiple Choice) Which cluster of assessment findings best
indicates acute decompensated heart failure with superimposed COPD exacerbation?
,A. Wheezing, prolonged expiration, and nasal flaring only
B. Crackles, JVD, +3 edema, orthopnea, elevated BNP, and weight gain
C. Fever 99.1°F, WBC 11,500, and glucose 142
D. HR 112 irregularly irregular and Hgb 10.8 only
Correct Answer: B. Crackles, JVD, +3 edema, orthopnea, elevated BNP, and weight
gain [CORRECT]
Rationale: This cluster represents systemic and pulmonary congestion (JVD, edema,
crackles, orthopnea, weight gain, elevated BNP) combined with COPD signs
(wheezing, prolonged expiration, accessory muscle use). CJMM Layer: Recognize
Cues.
Q2. (Recognize Cues — Multiple Response SATA) Select all assessment findings that
are ABNORMAL for this patient and require immediate nursing attention.
A. SpO2 86% on 2L nasal cannula
B. pH 7.32
C. PaCO2 58
D. HCO3 30
E. BNP 1200 pg/mL
F. K+ 3.2
G. RR 28
H. +3 pitting edema bilateral lower extremities
Correct Answer: A, B, C, E, F, G, H [CORRECT]
Rationale: All are abnormal except D (HCO3 30 is elevated indicating metabolic
compensation, which is an expected compensatory response rather than an acute
abnormality requiring immediate intervention) and the normal-ish glucose/WBC.
CJMM Layer: Recognize Cues.
Q3. (Analyze Cues — Multiple Choice) The nurse analyzes the ABG results. Which
interpretation is most accurate?
,A. Metabolic alkalosis with respiratory compensation
B. Respiratory acidosis with metabolic compensation (acute on chronic)
C. Metabolic acidosis with respiratory compensation
D. Respiratory alkalosis with metabolic compensation
Correct Answer: B. Respiratory acidosis with metabolic compensation (acute on
chronic) [CORRECT]
Rationale: pH 7.32 (acidemia), PaCO2 58 (respiratory acidosis), HCO3 30 (metabolic
compensation). Given COPD baseline, this represents acute on chronic respiratory
acidosis. CJMM Layer: Analyze Cues.
Q4. (Analyze Cues — Multiple Choice) The nurse differentiates between HF
exacerbation and COPD exacerbation. Which finding most specifically supports HF
exacerbation as the primary driver of decompensation?
A. Wheezing and prolonged expiration
B. JVD, +3 edema, and elevated BNP
C. PaCO2 58 and pH 7.32
D. Accessory muscle use and nasal flaring
Correct Answer: B. JVD, +3 edema, and elevated BNP [CORRECT]
Rationale: JVD, peripheral edema, and markedly elevated BNP are specific to fluid
overload and ventricular stretch in heart failure. Wheezing and hypercapnia are more
specific to COPD. CJMM Layer: Analyze Cues.
Q5. (Analyze Cues — Multiple Choice) Which complication is this patient at highest
risk for if the current hypercapnic respiratory failure is not promptly addressed?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Acute respiratory acidosis leading to altered mental status and respiratory arrest
D. Chronic compensated respiratory alkalosis
, Correct Answer: C. Acute respiratory acidosis leading to altered mental status and
respiratory arrest [CORRECT]
Rationale: Progressive hypercapnia (PaCO2 >60-70) causes CO2 narcosis, leading to
confusion, somnolence, asterixis, and potential respiratory arrest. CJMM Layer:
Analyze Cues.
Q6. (Prioritize Hypotheses — Multiple Choice) Based on the assessment and
diagnostic data, which condition should the nurse prioritize as the most likely and
most dangerous hypothesis?
A. Community-acquired pneumonia
B. Acute decompensated heart failure with superimposed COPD exacerbation
C. Pulmonary embolism
D. Acute coronary syndrome
Correct Answer: B. Acute decompensated heart failure with superimposed COPD
exacerbation [CORRECT]
Rationale: The combination of volume overload signs (JVD, edema, BNP elevation,
weight gain), pulmonary congestion (crackles, orthopnea, PND), and COPD signs
(wheezing, hypercapnia, accessory muscle use) best fits this dual diagnosis.
Pneumonia would show lobar consolidation; PE would show sudden dyspnea with
clear chest X-ray and possible D-dimer elevation. CJMM Layer: Prioritize Hypotheses.
Q7. (Prioritize Hypotheses — Multiple Choice) Which "can't miss" diagnosis must
the nurse consider and rule out given the patient's presentation?
A. Stable angina
B. Pulmonary embolism
C. Osteoarthritis
D. Hypothyroidism
Correct Answer: B. Pulmonary embolism [CORRECT]
