ATI MED SURG PROCTORED NGN RETAKE ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
Question 1
A nurse is caring for a client who is 2 days postoperative following
an appendectomy. The client reports pain as 7 on a 0-10 scale and
has a temperature of 38.8°C (101.8°F). The nurse assesses the
wound and notes redness and warmth with purulent drainage.
Which of the following actions should the nurse take first?
A) Administer a prescribed opioid analgesic.
B) Obtain a wound culture.
C) Notify the provider of the findings.
D) Document the assessment findings.
E) Apply a warm compress to the wound.
Correct Answer: C) Notify the provider of the findings.
Rationale: The client's symptoms (fever, increased pain, and
purulent drainage from the wound) are indicative of a wound
infection, which is a significant complication requiring immediate
medical evaluation and potential intervention. Notifying the
provider is the priority action to ensure prompt treatment.
Question 2
A nurse is providing discharge teaching to a client who has a new
prescription for enoxaparin. Which of the following statements by
the client indicates an understanding of the teaching?
A) "I will inject the medication into my thigh muscle."
B) "I will aspirate for blood return before injecting."
C) "I will rub the injection site vigorously after injecting."
D) "I will alternate injection sites on my abdomen."
E) "I will take this medication with meals."
Correct Answer: D) "I will alternate injection sites on my abdomen."
Rationale: Enoxaparin is a low molecular weight heparin
administered subcutaneously, typically in the abdomen, and
injection sites should be rotated to prevent tissue damage. It should
not be injected into muscle, aspirated, or rubbed, as these can
increase bruising and hematoma formation. It is not affected by
food.
Question 3
A nurse is caring for a client who has hypervolemia. Which of the
following laboratory findings should the nurse expect?
A) Increased hematocrit
,B) Decreased serum sodium
C) Increased serum osmolality
D) Increased urine specific gravity
E) Increased blood urea nitrogen (BUN)
Correct Answer: B) Decreased serum sodium
Rationale: Hypervolemia (fluid volume excess) leads to a dilutional
effect on electrolytes, causing a decrease in serum sodium
(hyponatremia) due to the excess water diluting the sodium
concentration. Hematocrit, serum osmolality, and BUN would likely
be decreased due to dilution, and urine specific gravity would be
decreased as the kidneys excrete excess water.
Question 4
A nurse is assessing a client who has a suspected fractured ankle.
Which of the following findings should the nurse identify as a
priority?
A) Pain rating of 6 on a 0-10 scale.
B) Swelling and ecchymosis around the ankle.
C) Inability to bear weight on the affected extremity.
D) Numbness and tingling in the toes.
E) Visible deformity of the ankle.
Correct Answer: D) Numbness and tingling in the toes.
Rationale: Numbness and tingling (paresthesia) in the toes distal to
the suspected fracture site can indicate nerve damage or, more
critically, compartment syndrome due to increased pressure
compromising circulation. This is a neurovascular impairment that
requires immediate attention to prevent permanent tissue damage.
While other options are signs of fracture, they are not immediately
life- or limb-threatening.
Question 5
A nurse is providing discharge teaching to a client who has heart
failure and a new prescription for furosemide. Which of the
following instructions should the nurse include?
A) "Increase your intake of sodium-rich foods."
B) "Take this medication at bedtime to promote sleep."
C) "Report a weight gain of 2 pounds in one day to your provider."
D) "This medication may cause constipation."
E) "Avoid consuming potassium-rich foods."
Correct Answer: C) "Report a weight gain of 2 pounds in one day to
your provider."
,Rationale: Furosemide is a potent loop diuretic used to reduce fluid
volume in heart failure. A rapid weight gain of 2-3 pounds in 24
hours (or 5 pounds in a week) indicates fluid retention and
worsening heart failure, requiring prompt notification of the
provider. Furosemide causes potassium loss, so increasing
potassium intake may be needed. It should be taken in the morning
to avoid nocturia.
Question 6
A nurse is caring for a client who has a new diagnosis of type 2
diabetes mellitus. The client asks, "What can I do to keep my blood
sugar under control?" Which of the following recommendations
should the nurse provide?
A) "Limit your intake of complex carbohydrates."
B) "Participate in regular physical activity."
C) "Take insulin injections daily."
D) "Avoid all sugary foods."
E) "You will need to be hospitalized for glycemic control."
Correct Answer: B) "Participate in regular physical activity."
Rationale: Regular physical activity is a cornerstone of type 2
diabetes management. It helps improve insulin sensitivity, promotes
weight loss, and lowers blood glucose levels. While dietary
modifications are also important, simply limiting complex carbs or
avoiding all sugary foods are not the sole or most comprehensive
answers. Insulin may or may not be needed for type 2 diabetes
initially, and hospitalization is not a routine first step.
Question 7
A nurse is preparing to administer an opioid analgesic to a client
who has a pain level of 8 on a 0-10 scale. The client's respiratory
rate is 8 breaths/min. Which of the following actions should the
nurse take?
A) Administer the opioid as prescribed and reassess in 30 minutes.
B) Withhold the opioid and notify the provider.
C) Administer a reduced dose of the opioid.
D) Obtain an order for naloxone to have on standby.
E) Encourage the client to take deep breaths.
Correct Answer: B) Withhold the opioid and notify the provider.
Rationale: A respiratory rate of 8 breaths/min is dangerously low
and indicates significant respiratory depression, a major adverse
effect of opioid analgesics. The nurse's priority is to withhold the
, medication and notify the provider immediately before
administering any opioid.
Question 8
A nurse is caring for a client who has Clostridium difficile (C. diff)
infection. Which of the following infection control precautions
should the nurse implement?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Standard precautions only
E) Protective environment
Correct Answer: C) Contact precautions
Rationale: Clostridium difficile is transmitted via the fecal-oral route
and requires contact precautions, which include wearing a gown and
gloves, and using soap and water for hand hygiene (alcohol-based
hand rubs are not effective against C. diff spores).
Question 9
A nurse is assessing a client who has a traumatic brain injury (TBI)
and notes a GCS score of 7. Which of the following nursing
interventions is the priority?
A) Administering a prescribed sedative.
B) Elevating the head of the bed to 30 degrees.
C) Preparing for endotracheal intubation.
D) Performing frequent neurological assessments.
E) Inserting an indwelling urinary catheter.
Correct Answer: C) Preparing for endotracheal intubation.
Rationale: A GCS score of 8 or less indicates severe TBI and an
inability to protect the airway. Preparing for endotracheal
intubation to secure the airway and ensure adequate ventilation is
the priority to prevent secondary brain injury from hypoxia and
hypercapnia.
Question 10
A nurse is providing teaching to a client who has a new permanent
pacemaker. Which of the following statements by the client
indicates a need for further teaching?
A) "I should avoid standing near microwave ovens."
B) "I will check my pulse daily and report any changes."
C) "I can use my cell phone on the ear opposite the pacemaker."
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
Question 1
A nurse is caring for a client who is 2 days postoperative following
an appendectomy. The client reports pain as 7 on a 0-10 scale and
has a temperature of 38.8°C (101.8°F). The nurse assesses the
wound and notes redness and warmth with purulent drainage.
Which of the following actions should the nurse take first?
A) Administer a prescribed opioid analgesic.
B) Obtain a wound culture.
C) Notify the provider of the findings.
D) Document the assessment findings.
E) Apply a warm compress to the wound.
Correct Answer: C) Notify the provider of the findings.
Rationale: The client's symptoms (fever, increased pain, and
purulent drainage from the wound) are indicative of a wound
infection, which is a significant complication requiring immediate
medical evaluation and potential intervention. Notifying the
provider is the priority action to ensure prompt treatment.
Question 2
A nurse is providing discharge teaching to a client who has a new
prescription for enoxaparin. Which of the following statements by
the client indicates an understanding of the teaching?
A) "I will inject the medication into my thigh muscle."
B) "I will aspirate for blood return before injecting."
C) "I will rub the injection site vigorously after injecting."
D) "I will alternate injection sites on my abdomen."
E) "I will take this medication with meals."
Correct Answer: D) "I will alternate injection sites on my abdomen."
Rationale: Enoxaparin is a low molecular weight heparin
administered subcutaneously, typically in the abdomen, and
injection sites should be rotated to prevent tissue damage. It should
not be injected into muscle, aspirated, or rubbed, as these can
increase bruising and hematoma formation. It is not affected by
food.
Question 3
A nurse is caring for a client who has hypervolemia. Which of the
following laboratory findings should the nurse expect?
A) Increased hematocrit
,B) Decreased serum sodium
C) Increased serum osmolality
D) Increased urine specific gravity
E) Increased blood urea nitrogen (BUN)
Correct Answer: B) Decreased serum sodium
Rationale: Hypervolemia (fluid volume excess) leads to a dilutional
effect on electrolytes, causing a decrease in serum sodium
(hyponatremia) due to the excess water diluting the sodium
concentration. Hematocrit, serum osmolality, and BUN would likely
be decreased due to dilution, and urine specific gravity would be
decreased as the kidneys excrete excess water.
Question 4
A nurse is assessing a client who has a suspected fractured ankle.
Which of the following findings should the nurse identify as a
priority?
A) Pain rating of 6 on a 0-10 scale.
B) Swelling and ecchymosis around the ankle.
C) Inability to bear weight on the affected extremity.
D) Numbness and tingling in the toes.
E) Visible deformity of the ankle.
Correct Answer: D) Numbness and tingling in the toes.
Rationale: Numbness and tingling (paresthesia) in the toes distal to
the suspected fracture site can indicate nerve damage or, more
critically, compartment syndrome due to increased pressure
compromising circulation. This is a neurovascular impairment that
requires immediate attention to prevent permanent tissue damage.
While other options are signs of fracture, they are not immediately
life- or limb-threatening.
Question 5
A nurse is providing discharge teaching to a client who has heart
failure and a new prescription for furosemide. Which of the
following instructions should the nurse include?
A) "Increase your intake of sodium-rich foods."
B) "Take this medication at bedtime to promote sleep."
C) "Report a weight gain of 2 pounds in one day to your provider."
D) "This medication may cause constipation."
E) "Avoid consuming potassium-rich foods."
Correct Answer: C) "Report a weight gain of 2 pounds in one day to
your provider."
,Rationale: Furosemide is a potent loop diuretic used to reduce fluid
volume in heart failure. A rapid weight gain of 2-3 pounds in 24
hours (or 5 pounds in a week) indicates fluid retention and
worsening heart failure, requiring prompt notification of the
provider. Furosemide causes potassium loss, so increasing
potassium intake may be needed. It should be taken in the morning
to avoid nocturia.
Question 6
A nurse is caring for a client who has a new diagnosis of type 2
diabetes mellitus. The client asks, "What can I do to keep my blood
sugar under control?" Which of the following recommendations
should the nurse provide?
A) "Limit your intake of complex carbohydrates."
B) "Participate in regular physical activity."
C) "Take insulin injections daily."
D) "Avoid all sugary foods."
E) "You will need to be hospitalized for glycemic control."
Correct Answer: B) "Participate in regular physical activity."
Rationale: Regular physical activity is a cornerstone of type 2
diabetes management. It helps improve insulin sensitivity, promotes
weight loss, and lowers blood glucose levels. While dietary
modifications are also important, simply limiting complex carbs or
avoiding all sugary foods are not the sole or most comprehensive
answers. Insulin may or may not be needed for type 2 diabetes
initially, and hospitalization is not a routine first step.
Question 7
A nurse is preparing to administer an opioid analgesic to a client
who has a pain level of 8 on a 0-10 scale. The client's respiratory
rate is 8 breaths/min. Which of the following actions should the
nurse take?
A) Administer the opioid as prescribed and reassess in 30 minutes.
B) Withhold the opioid and notify the provider.
C) Administer a reduced dose of the opioid.
D) Obtain an order for naloxone to have on standby.
E) Encourage the client to take deep breaths.
Correct Answer: B) Withhold the opioid and notify the provider.
Rationale: A respiratory rate of 8 breaths/min is dangerously low
and indicates significant respiratory depression, a major adverse
effect of opioid analgesics. The nurse's priority is to withhold the
, medication and notify the provider immediately before
administering any opioid.
Question 8
A nurse is caring for a client who has Clostridium difficile (C. diff)
infection. Which of the following infection control precautions
should the nurse implement?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Standard precautions only
E) Protective environment
Correct Answer: C) Contact precautions
Rationale: Clostridium difficile is transmitted via the fecal-oral route
and requires contact precautions, which include wearing a gown and
gloves, and using soap and water for hand hygiene (alcohol-based
hand rubs are not effective against C. diff spores).
Question 9
A nurse is assessing a client who has a traumatic brain injury (TBI)
and notes a GCS score of 7. Which of the following nursing
interventions is the priority?
A) Administering a prescribed sedative.
B) Elevating the head of the bed to 30 degrees.
C) Preparing for endotracheal intubation.
D) Performing frequent neurological assessments.
E) Inserting an indwelling urinary catheter.
Correct Answer: C) Preparing for endotracheal intubation.
Rationale: A GCS score of 8 or less indicates severe TBI and an
inability to protect the airway. Preparing for endotracheal
intubation to secure the airway and ensure adequate ventilation is
the priority to prevent secondary brain injury from hypoxia and
hypercapnia.
Question 10
A nurse is providing teaching to a client who has a new permanent
pacemaker. Which of the following statements by the client
indicates a need for further teaching?
A) "I should avoid standing near microwave ovens."
B) "I will check my pulse daily and report any changes."
C) "I can use my cell phone on the ear opposite the pacemaker."
