NGN ATI RN Comprehensive Exit Retake Exam (Versions 1–4)
– Complete Question and Answer Guide (Verified 2025/2026
Edition)
1. A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lb) in 24 hours. Which action
should the nurse take first?
A) Administer furosemide IV push
B) Auscultate lung sounds
C) Restrict oral fluids to 1 L/day
D) Weigh the client again
Answer: B – Explanation: The nurse should first assess lung sounds to determine if the weight gain is due
to fluid overload (crackles, dyspnea). Diuretics are given after assessment.
2. A nurse is teaching a client with type 1 diabetes about sick-day management. Which statement
indicates understanding?
A) “I will stop my insulin if I cannot eat.”
B) “I will check my blood glucose every 4 hours.”
C) “I will drink sugar-free liquids only.”
D) “I will take my regular insulin dose even if I vomit.”
Answer: B – Explanation: During sick days, blood glucose should be checked every 4 hours. Never stop
insulin; may need supplemental doses. Drink fluids with sugar if glucose low.
3. A client with major depressive disorder is started on phenelzine (MAOI). Which food should the nurse
instruct the client to avoid?
A) Broiled chicken
B) Aged cheese
C) Green beans
D) White rice
,Answer: B – Explanation: MAOIs require a tyramine-restricted diet. Aged cheese, cured meats,
fermented foods, and red wine can cause hypertensive crisis.
4. A nurse is assessing a client who is 2 hours postoperative following a thyroidectomy. Which finding
requires immediate intervention?
A) Hoarse voice
B) Tingling around the mouth
C) Pain at the incision site
D) Temperature 99.2°F (37.3°C)
Answer: B – Explanation: Tingling around the mouth indicates hypocalcemia due to accidental
parathyroid removal. This can progress to tetany and laryngospasm. Notify provider immediately.
5. A nurse is caring for a client with cirrhosis who has an ammonia level of 150 mcg/dL (normal 10–80).
Which medication should the nurse prepare to administer?
A) Furosemide
B) Lactulose
C) Spironolactone
D) Propranolol
Answer: B – Explanation: Lactulose reduces serum ammonia by promoting excretion in the GI tract. Used
to treat hepatic encephalopathy.
6. A nurse is providing discharge teaching to a client with a new prescription for warfarin. Which
statement indicates a need for further teaching?
A) “I will use a soft toothbrush.”
B) “I will eat more green leafy vegetables.”
C) “I will avoid drinking alcohol.”
D) “I will report any bruising to my provider.”
Answer: B – Explanation: Green leafy vegetables are high in vitamin K, which antagonizes warfarin.
Clients should maintain consistent vitamin K intake, not increase it.
7. A nurse is assessing a client who is 24 hours post‑myocardial infarction. The client reports chest pain
that is relieved by nitroglycerin. Which complication should the nurse suspect?
,A) Pericarditis
B) Recurrent infarction
C) Heart failure
D) Pulmonary embolism
Answer: A – Explanation: Post-MI pericarditis (Dressler’s syndrome) typically occurs days to weeks later,
but early pericarditis can cause pain that improves with leaning forward and may respond to
nitroglycerin? Actually, nitroglycerin may not relieve pericardial pain. Recurrent infarction is more likely.
However, standard teaching: chest pain after MI that is relieved by nitroglycerin suggests new ischemia.
So answer B is correct. But let’s be precise: Post-MI chest pain relieved by nitroglycerin is likely recurrent
ischemia. So answer B.
8. A nurse is caring for a client with a chest tube connected to water seal drainage. The nurse notes
continuous bubbling in the water seal chamber. What is the priority action?
A) Clamp the chest tube
B) Check for an air leak in the system
C) Increase suction pressure
D) Document as normal finding
Answer: B – Explanation: Continuous bubbling indicates an air leak. Assess connections and tubing.
Clamping is not first-line and could cause tension pneumothorax.
9. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which ECG finding should the
nurse expect?
A) Peaked T waves
B) Flat T waves
C) Prominent U waves
D) Prolonged QT interval
Answer: A – Explanation: Hyperkalemia causes peaked T waves, widened QRS, and eventually sine wave.
Flat T waves and U waves are seen in hypokalemia.
10. A nurse is teaching a client with asthma about using a peak flow meter. Which statement indicates
correct understanding?
A) “I will use my peak flow meter after taking my rescue inhaler.”
, B) “I will record the lowest of three readings.”
C) “I will use the meter when I feel short of breath.”
D) “I will stand up and take a deep breath before blowing out hard.”
Answer: D – Explanation: Peak flow should be done standing, take a deep breath, then blow out as hard
and fast as possible. Record the highest of three readings. Use daily even when asymptomatic.
11. A nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The TPN
bag is empty, and a new bag is not available. What should the nurse do?
A) Hang dextrose 10% in water until the new bag arrives
B) Hang lactated Ringer’s solution
C) Discontinue the IV line
D) Flush the line with normal saline and cap it
Answer: A – Explanation: To prevent hypoglycemia from sudden TPN discontinuation, hang dextrose
10% or 20% at the same rate until TPN is available.
12. A client with schizophrenia is experiencing auditory hallucinations. Which response by the nurse is
most therapeutic?
A) “I don’t hear any voices. You are imagining things.”
B) “Tell me what the voices are saying to you.”
C) “Let’s go to my office to talk about your feelings.”
D) “The voices are not real. Try to ignore them.”
Answer: B – Explanation: Assess the content of hallucinations to determine if they are commanding or
dangerous. Do not argue or deny the client’s experience.
13. A nurse is preparing to administer digoxin to a client with heart failure. Which finding should cause
the nurse to hold the dose?
A) Heart rate 58 bpm
B) Potassium level 4.0 mEq/L
C) Blood pressure 110/70 mmHg
D) Respiratory rate 16/min
– Complete Question and Answer Guide (Verified 2025/2026
Edition)
1. A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lb) in 24 hours. Which action
should the nurse take first?
A) Administer furosemide IV push
B) Auscultate lung sounds
C) Restrict oral fluids to 1 L/day
D) Weigh the client again
Answer: B – Explanation: The nurse should first assess lung sounds to determine if the weight gain is due
to fluid overload (crackles, dyspnea). Diuretics are given after assessment.
2. A nurse is teaching a client with type 1 diabetes about sick-day management. Which statement
indicates understanding?
A) “I will stop my insulin if I cannot eat.”
B) “I will check my blood glucose every 4 hours.”
C) “I will drink sugar-free liquids only.”
D) “I will take my regular insulin dose even if I vomit.”
Answer: B – Explanation: During sick days, blood glucose should be checked every 4 hours. Never stop
insulin; may need supplemental doses. Drink fluids with sugar if glucose low.
3. A client with major depressive disorder is started on phenelzine (MAOI). Which food should the nurse
instruct the client to avoid?
A) Broiled chicken
B) Aged cheese
C) Green beans
D) White rice
,Answer: B – Explanation: MAOIs require a tyramine-restricted diet. Aged cheese, cured meats,
fermented foods, and red wine can cause hypertensive crisis.
4. A nurse is assessing a client who is 2 hours postoperative following a thyroidectomy. Which finding
requires immediate intervention?
A) Hoarse voice
B) Tingling around the mouth
C) Pain at the incision site
D) Temperature 99.2°F (37.3°C)
Answer: B – Explanation: Tingling around the mouth indicates hypocalcemia due to accidental
parathyroid removal. This can progress to tetany and laryngospasm. Notify provider immediately.
5. A nurse is caring for a client with cirrhosis who has an ammonia level of 150 mcg/dL (normal 10–80).
Which medication should the nurse prepare to administer?
A) Furosemide
B) Lactulose
C) Spironolactone
D) Propranolol
Answer: B – Explanation: Lactulose reduces serum ammonia by promoting excretion in the GI tract. Used
to treat hepatic encephalopathy.
6. A nurse is providing discharge teaching to a client with a new prescription for warfarin. Which
statement indicates a need for further teaching?
A) “I will use a soft toothbrush.”
B) “I will eat more green leafy vegetables.”
C) “I will avoid drinking alcohol.”
D) “I will report any bruising to my provider.”
Answer: B – Explanation: Green leafy vegetables are high in vitamin K, which antagonizes warfarin.
Clients should maintain consistent vitamin K intake, not increase it.
7. A nurse is assessing a client who is 24 hours post‑myocardial infarction. The client reports chest pain
that is relieved by nitroglycerin. Which complication should the nurse suspect?
,A) Pericarditis
B) Recurrent infarction
C) Heart failure
D) Pulmonary embolism
Answer: A – Explanation: Post-MI pericarditis (Dressler’s syndrome) typically occurs days to weeks later,
but early pericarditis can cause pain that improves with leaning forward and may respond to
nitroglycerin? Actually, nitroglycerin may not relieve pericardial pain. Recurrent infarction is more likely.
However, standard teaching: chest pain after MI that is relieved by nitroglycerin suggests new ischemia.
So answer B is correct. But let’s be precise: Post-MI chest pain relieved by nitroglycerin is likely recurrent
ischemia. So answer B.
8. A nurse is caring for a client with a chest tube connected to water seal drainage. The nurse notes
continuous bubbling in the water seal chamber. What is the priority action?
A) Clamp the chest tube
B) Check for an air leak in the system
C) Increase suction pressure
D) Document as normal finding
Answer: B – Explanation: Continuous bubbling indicates an air leak. Assess connections and tubing.
Clamping is not first-line and could cause tension pneumothorax.
9. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which ECG finding should the
nurse expect?
A) Peaked T waves
B) Flat T waves
C) Prominent U waves
D) Prolonged QT interval
Answer: A – Explanation: Hyperkalemia causes peaked T waves, widened QRS, and eventually sine wave.
Flat T waves and U waves are seen in hypokalemia.
10. A nurse is teaching a client with asthma about using a peak flow meter. Which statement indicates
correct understanding?
A) “I will use my peak flow meter after taking my rescue inhaler.”
, B) “I will record the lowest of three readings.”
C) “I will use the meter when I feel short of breath.”
D) “I will stand up and take a deep breath before blowing out hard.”
Answer: D – Explanation: Peak flow should be done standing, take a deep breath, then blow out as hard
and fast as possible. Record the highest of three readings. Use daily even when asymptomatic.
11. A nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The TPN
bag is empty, and a new bag is not available. What should the nurse do?
A) Hang dextrose 10% in water until the new bag arrives
B) Hang lactated Ringer’s solution
C) Discontinue the IV line
D) Flush the line with normal saline and cap it
Answer: A – Explanation: To prevent hypoglycemia from sudden TPN discontinuation, hang dextrose
10% or 20% at the same rate until TPN is available.
12. A client with schizophrenia is experiencing auditory hallucinations. Which response by the nurse is
most therapeutic?
A) “I don’t hear any voices. You are imagining things.”
B) “Tell me what the voices are saying to you.”
C) “Let’s go to my office to talk about your feelings.”
D) “The voices are not real. Try to ignore them.”
Answer: B – Explanation: Assess the content of hallucinations to determine if they are commanding or
dangerous. Do not argue or deny the client’s experience.
13. A nurse is preparing to administer digoxin to a client with heart failure. Which finding should cause
the nurse to hold the dose?
A) Heart rate 58 bpm
B) Potassium level 4.0 mEq/L
C) Blood pressure 110/70 mmHg
D) Respiratory rate 16/min
