ATI RN Medical Surgical Proctored Exam 2023 Advanced Prep: Master NGN
Case Studies & Practice Questions
Subject: Medical-Surgical Nursing / Subtopic: Next Generation NCLEX (NGN) Clinical
Judgment and Advanced Management of Care
Question 1: A nurse is caring for a client who is 6 hours post-operative following an exploratory
laparotomy. The client's initial assessment reveals a blood pressure of 88/50 mmHg, a heart rate
of 124 bpm, and cool, pale, clammy skin. The surgical dressing is dry and intact. Which of the
following is the priority nursing action?
A) Increase the rate of the maintenance IV fluids.
B) Place the client in a Trendelenburg position.
C) Notify the surgeon of suspected internal hemorrhage.
D) Administer the prescribed PRN analgesic for reported incisional pain.
Correct Answer: C) Notify the surgeon of suspected internal hemorrhage.
Explanation: The client is exhibiting classic signs of hypovolemic shock (tachycardia,
hypotension, cool/clammy skin) in the early post-operative period. While the dressing is dry,
internal bleeding is a significant risk following abdominal surgery. The nurse must immediately
alert the surgeon for potential surgical re-exploration. Trendelenburg is no longer recommended
due to potential negative impacts on respiratory status, and analgesics may mask symptoms or
lower BP further.
Question 2: A nurse is managing a client with a history of heart failure who is receiving an IV
infusion of furosemide 40 mg. The client reports muscle weakness, tingling in the fingers, and
palpitations. Which laboratory result should the nurse anticipate?
A) Serum potassium 3.1 mEq/L
B) Serum potassium 5.6 mEq/L
C) Serum sodium 145 mEq/L
D) Serum magnesium 2.2 mEq/L
Correct Answer: A) Serum potassium 3.1 mEq/L
Explanation: Loop diuretics like furosemide inhibit sodium and chloride reabsorption, which
leads to significant potassium loss. The symptoms (weakness, tingling, palpitations) are classic
signs of hypokalemia. A potassium level of 3.1 mEq/L is hypokalemic. Hyperkalemia (5.6) would
present with different ECG changes, and the other values are within or near normal limits.
,Question 3: A nurse is caring for a client with a new diagnosis of diabetes mellitus who is
learning to administer insulin. Which of the following client actions indicates that the nurse
needs to provide further teaching?
A) The client rotates injection sites within the same anatomical region.
B) The client cleans the injection site with an alcohol swab and allows it to dry.
C) The client pulls the skin taut before inserting the needle at a 90-degree angle.
D) The client stores the currently used insulin vial in the freezer.
Correct Answer: D) The client stores the currently used insulin vial in the freezer.
Explanation: Insulin must never be frozen, as freezing destroys the protein structure, rendering it
ineffective. Insulin should be stored at room temperature once in use or in the refrigerator for
long-term storage. The other actions (rotating sites, cleaning, and correct injection technique)
are appropriate.
Question 4: A nurse is caring for a client who is in the emergent phase of a severe burn injury.
Which laboratory finding warrants the most immediate intervention?
A) Serum sodium 130 mEq/L
B) Serum potassium 6.2 mEq/L
C) Hematocrit 50%
D) White blood cell count 11,000/mm³
Correct Answer: B) Serum potassium 6.2 mEq/L
Explanation: During the emergent phase of a burn, massive tissue destruction causes
intracellular potassium to be released into the extracellular space, leading to life-threatening
hyperkalemia. A level of 6.2 mEq/L places the client at immediate risk for cardiac dysrhythmias
and arrest. Hyponatremia and elevated hematocrit are common expected findings in the initial
burn phase.
Question 5: A nurse is providing discharge teaching for a client with a permanent colostomy.
Which of the following client statements indicates a need for further instruction?
A) "I will avoid foods that cause excessive gas, such as cabbage and beans."
B) "I should notify my provider if the stoma becomes dark purple or black."
C) "I will change the entire appliance system every single day to prevent infection."
,D) "I will monitor the peristomal skin for any signs of redness or irritation."
Correct Answer: C) "I will change the entire appliance system every single day to prevent
infection."
Explanation: Changing a colostomy appliance daily is unnecessary and can cause skin
excoriation and irritation. Most systems are designed to be changed every 3–7 days. Daily
changes are not standard practice and increase the risk of skin breakdown. The other statements
demonstrate correct understanding of stoma care.
Question 6: A nurse is caring for a client with a chest tube that is connected to a closed-chest
drainage system. The nurse observes that the water in the seal chamber is no longer fluctuating
(tidaling) with the client's respirations. Which of the following is the most appropriate nursing
action?
A) Increase the amount of suction on the drainage system.
B) Check the tubing for kinks or evidence of occlusion.
C) Notify the provider to request the removal of the chest tube.
D) Prepare the client for a repeat chest X-ray.
Correct Answer: B) Check the tubing for kinks or obstruction.
Explanation: Tidaling (oscillation in the water-seal chamber) reflects the normal changes in
intrathoracic pressure during the respiratory cycle. If tidaling stops, the nurse must first assess
for a kink or obstruction in the tubing. If the lung has fully re-expanded, the tube will no longer
fluctuate, but the nurse must rule out an obstruction first.
Question 7: A nurse is caring for a client who is 2 days post-operative following a
thyroidectomy. The nurse notes the client has developed muscle twitching around the mouth and
a positive Trousseau's sign. What is the priority nursing action?
A) Notify the surgeon and prepare to administer IV calcium gluconate.
B) Administer the prescribed PRN thyroid replacement medication.
C) Instruct the client to perform controlled breathing exercises.
D) Elevate the head of the bed to 45 degrees.
Correct Answer: A) Notify the surgeon and prepare to administer IV calcium gluconate.
Explanation: Muscle twitching and a positive Trousseau’s sign are indications of hypocalcemia,
a potential complication of a thyroidectomy due to accidental injury to the parathyroid glands.
, Hypocalcemia can lead to tetany and airway obstruction; therefore, this is an emergency
requiring immediate intervention with calcium supplementation.
Question 8: A nurse is delegating care for a client with a history of acute pancreatitis. Which task
is appropriate to delegate to an experienced UAP?
A) Assessing the client's pain level using a numeric rating scale.
B) Obtaining the client's daily weight.
C) Evaluating the effectiveness of the client’s nutritional intake.
D) Determining the client’s risk for aspiration during enteral feeding.
Correct Answer: B) Obtaining the client's daily weight.
Explanation: Obtaining and documenting a daily weight is a standard task that can be delegated
to a UAP. Assessing pain, evaluating nutritional progress, and determining aspiration risk
involve clinical judgment and the nursing process, which are within the scope of the RN only.
Question 9: A nurse is assessing a client for the signs of fluid volume excess. Which of the
following findings is the most reliable clinical indicator?
A) Increased urine output
B) Distended neck veins
C) Decreased blood pressure
D) Dry oral mucous membranes
Correct Answer: B) Distended neck veins
Explanation: Distended neck veins (jugular venous distention) indicate increased central venous
pressure and are a hallmark sign of fluid volume overload. Increased urine output is often a
compensatory mechanism; however, distended veins are a more direct clinical indicator of fluid
overload.
Question 10: A nurse is caring for a client with a history of COPD who is receiving supplemental
oxygen. Which of the following assessment findings suggests that the client is experiencing
carbon dioxide retention?
A) Increased respiratory rate of 28 breaths per minute.
B) Sudden onset of confusion and restlessness.
Case Studies & Practice Questions
Subject: Medical-Surgical Nursing / Subtopic: Next Generation NCLEX (NGN) Clinical
Judgment and Advanced Management of Care
Question 1: A nurse is caring for a client who is 6 hours post-operative following an exploratory
laparotomy. The client's initial assessment reveals a blood pressure of 88/50 mmHg, a heart rate
of 124 bpm, and cool, pale, clammy skin. The surgical dressing is dry and intact. Which of the
following is the priority nursing action?
A) Increase the rate of the maintenance IV fluids.
B) Place the client in a Trendelenburg position.
C) Notify the surgeon of suspected internal hemorrhage.
D) Administer the prescribed PRN analgesic for reported incisional pain.
Correct Answer: C) Notify the surgeon of suspected internal hemorrhage.
Explanation: The client is exhibiting classic signs of hypovolemic shock (tachycardia,
hypotension, cool/clammy skin) in the early post-operative period. While the dressing is dry,
internal bleeding is a significant risk following abdominal surgery. The nurse must immediately
alert the surgeon for potential surgical re-exploration. Trendelenburg is no longer recommended
due to potential negative impacts on respiratory status, and analgesics may mask symptoms or
lower BP further.
Question 2: A nurse is managing a client with a history of heart failure who is receiving an IV
infusion of furosemide 40 mg. The client reports muscle weakness, tingling in the fingers, and
palpitations. Which laboratory result should the nurse anticipate?
A) Serum potassium 3.1 mEq/L
B) Serum potassium 5.6 mEq/L
C) Serum sodium 145 mEq/L
D) Serum magnesium 2.2 mEq/L
Correct Answer: A) Serum potassium 3.1 mEq/L
Explanation: Loop diuretics like furosemide inhibit sodium and chloride reabsorption, which
leads to significant potassium loss. The symptoms (weakness, tingling, palpitations) are classic
signs of hypokalemia. A potassium level of 3.1 mEq/L is hypokalemic. Hyperkalemia (5.6) would
present with different ECG changes, and the other values are within or near normal limits.
,Question 3: A nurse is caring for a client with a new diagnosis of diabetes mellitus who is
learning to administer insulin. Which of the following client actions indicates that the nurse
needs to provide further teaching?
A) The client rotates injection sites within the same anatomical region.
B) The client cleans the injection site with an alcohol swab and allows it to dry.
C) The client pulls the skin taut before inserting the needle at a 90-degree angle.
D) The client stores the currently used insulin vial in the freezer.
Correct Answer: D) The client stores the currently used insulin vial in the freezer.
Explanation: Insulin must never be frozen, as freezing destroys the protein structure, rendering it
ineffective. Insulin should be stored at room temperature once in use or in the refrigerator for
long-term storage. The other actions (rotating sites, cleaning, and correct injection technique)
are appropriate.
Question 4: A nurse is caring for a client who is in the emergent phase of a severe burn injury.
Which laboratory finding warrants the most immediate intervention?
A) Serum sodium 130 mEq/L
B) Serum potassium 6.2 mEq/L
C) Hematocrit 50%
D) White blood cell count 11,000/mm³
Correct Answer: B) Serum potassium 6.2 mEq/L
Explanation: During the emergent phase of a burn, massive tissue destruction causes
intracellular potassium to be released into the extracellular space, leading to life-threatening
hyperkalemia. A level of 6.2 mEq/L places the client at immediate risk for cardiac dysrhythmias
and arrest. Hyponatremia and elevated hematocrit are common expected findings in the initial
burn phase.
Question 5: A nurse is providing discharge teaching for a client with a permanent colostomy.
Which of the following client statements indicates a need for further instruction?
A) "I will avoid foods that cause excessive gas, such as cabbage and beans."
B) "I should notify my provider if the stoma becomes dark purple or black."
C) "I will change the entire appliance system every single day to prevent infection."
,D) "I will monitor the peristomal skin for any signs of redness or irritation."
Correct Answer: C) "I will change the entire appliance system every single day to prevent
infection."
Explanation: Changing a colostomy appliance daily is unnecessary and can cause skin
excoriation and irritation. Most systems are designed to be changed every 3–7 days. Daily
changes are not standard practice and increase the risk of skin breakdown. The other statements
demonstrate correct understanding of stoma care.
Question 6: A nurse is caring for a client with a chest tube that is connected to a closed-chest
drainage system. The nurse observes that the water in the seal chamber is no longer fluctuating
(tidaling) with the client's respirations. Which of the following is the most appropriate nursing
action?
A) Increase the amount of suction on the drainage system.
B) Check the tubing for kinks or evidence of occlusion.
C) Notify the provider to request the removal of the chest tube.
D) Prepare the client for a repeat chest X-ray.
Correct Answer: B) Check the tubing for kinks or obstruction.
Explanation: Tidaling (oscillation in the water-seal chamber) reflects the normal changes in
intrathoracic pressure during the respiratory cycle. If tidaling stops, the nurse must first assess
for a kink or obstruction in the tubing. If the lung has fully re-expanded, the tube will no longer
fluctuate, but the nurse must rule out an obstruction first.
Question 7: A nurse is caring for a client who is 2 days post-operative following a
thyroidectomy. The nurse notes the client has developed muscle twitching around the mouth and
a positive Trousseau's sign. What is the priority nursing action?
A) Notify the surgeon and prepare to administer IV calcium gluconate.
B) Administer the prescribed PRN thyroid replacement medication.
C) Instruct the client to perform controlled breathing exercises.
D) Elevate the head of the bed to 45 degrees.
Correct Answer: A) Notify the surgeon and prepare to administer IV calcium gluconate.
Explanation: Muscle twitching and a positive Trousseau’s sign are indications of hypocalcemia,
a potential complication of a thyroidectomy due to accidental injury to the parathyroid glands.
, Hypocalcemia can lead to tetany and airway obstruction; therefore, this is an emergency
requiring immediate intervention with calcium supplementation.
Question 8: A nurse is delegating care for a client with a history of acute pancreatitis. Which task
is appropriate to delegate to an experienced UAP?
A) Assessing the client's pain level using a numeric rating scale.
B) Obtaining the client's daily weight.
C) Evaluating the effectiveness of the client’s nutritional intake.
D) Determining the client’s risk for aspiration during enteral feeding.
Correct Answer: B) Obtaining the client's daily weight.
Explanation: Obtaining and documenting a daily weight is a standard task that can be delegated
to a UAP. Assessing pain, evaluating nutritional progress, and determining aspiration risk
involve clinical judgment and the nursing process, which are within the scope of the RN only.
Question 9: A nurse is assessing a client for the signs of fluid volume excess. Which of the
following findings is the most reliable clinical indicator?
A) Increased urine output
B) Distended neck veins
C) Decreased blood pressure
D) Dry oral mucous membranes
Correct Answer: B) Distended neck veins
Explanation: Distended neck veins (jugular venous distention) indicate increased central venous
pressure and are a hallmark sign of fluid volume overload. Increased urine output is often a
compensatory mechanism; however, distended veins are a more direct clinical indicator of fluid
overload.
Question 10: A nurse is caring for a client with a history of COPD who is receiving supplemental
oxygen. Which of the following assessment findings suggests that the client is experiencing
carbon dioxide retention?
A) Increased respiratory rate of 28 breaths per minute.
B) Sudden onset of confusion and restlessness.
