ATI PN ADULT MEDICAL SURGICAL
Proctored Exam
NGN Content Mastery Series
2023
Questions and Answers
with Rationales
,1. A nurse is reviewing the medical record of a client who has a prescription for
morphine. Which of the following findings should the nurse report to the provider?
A) Respiratory rate of 14/min
B) Blood pressure of 118/76 mmHg
C) Urinary retention
D) Mild constipation
Answer: C) Urinary retention
Rationale: Urinary retention is a serious adverse effect of morphine that requires
provider notification. Morphine can cause urinary retention by increasing smooth
muscle tone in the bladder sphincter, which can lead to urinary obstruction if not
addressed.
2. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of
the following actions should the nurse take?
A) Apply a heating pad to bony prominences
B) Massage reddened bony prominence areas vigorously
C) Position pillows between the bony prominences
D) Keep the head of bed elevated at 45 degrees at all times
Answer: C) Position pillows between the bony prominences
Rationale: Placing pillows between bony prominences (such as the knees and ankles)
reduces direct pressure and friction on vulnerable skin areas, thereby decreasing the
risk of pressure ulcer development.
,3. A nurse is caring for a client who is postoperative and is receiving an IV infusion of
cefazolin. Ten minutes after beginning the infusion, the client reports intense itching.
Which of the following actions should the nurse take first?
A) Administer diphenhydramine IV
B) Notify the provider immediately
C) Slow the infusion rate
D) Stop the medication infusion
Answer: D) Stop the medication infusion
Rationale: Intense itching shortly after starting an antibiotic infusion suggests a
hypersensitivity or allergic reaction. The first priority is to stop the infusion to prevent
further exposure to the allergen and to prevent the reaction from escalating to
anaphylaxis.
4. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the
following information should the nurse include?
A) The infection can be cured with a single dose of acetaminophen
B) Sexual partners do not require treatment unless they show symptoms
C) You are at risk for infertility with this infection, regardless of treatment
D) This infection provides immunity against future gonorrhea infections
Answer: C) You are at risk for infertility with this infection, regardless of treatment
Rationale: Gonorrhea can cause scarring and damage to the reproductive tract, which
may lead to infertility even after successful treatment. Clients should be counseled
about this risk to encourage follow-up care and prevention of reinfection.
, 5. A nurse is examining a client's IV site and notes a red line up his arm. The client
reports a throbbing, burning pain at the IV site. The nurse should identify that the
client's manifestations indicate which of the following complications?
A) Infiltration
B) Phlebitis
C) Thrombophlebitis
D) Extravasation
Answer: C) Thrombophlebitis
Rationale: Thrombophlebitis is characterized by inflammation of a vein with clot
formation, presenting with a red streak (red line) along the vein tract, along with
throbbing and burning pain at the IV site. The red line differentiates it from simple
phlebitis.
6. A nurse is reinforcing teaching with an adolescent client regarding testicular self-
examination. Which of the following statements by the client demonstrates an
understanding of the teaching?
A) "I should examine my testicles once a year during a warm bath."
B) "I understand that testicular cancer is painless."
C) "I should report any smooth, firm areas to my doctor."
D) "Hard lumps are usually normal and nothing to worry about."
Answer: B) "I understand that testicular cancer is painless."
Rationale: Testicular cancer is typically painless in its early stages. Educating the
client that a painless lump or mass warrants immediate medical evaluation is key to
early detection and improved outcomes.
Proctored Exam
NGN Content Mastery Series
2023
Questions and Answers
with Rationales
,1. A nurse is reviewing the medical record of a client who has a prescription for
morphine. Which of the following findings should the nurse report to the provider?
A) Respiratory rate of 14/min
B) Blood pressure of 118/76 mmHg
C) Urinary retention
D) Mild constipation
Answer: C) Urinary retention
Rationale: Urinary retention is a serious adverse effect of morphine that requires
provider notification. Morphine can cause urinary retention by increasing smooth
muscle tone in the bladder sphincter, which can lead to urinary obstruction if not
addressed.
2. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of
the following actions should the nurse take?
A) Apply a heating pad to bony prominences
B) Massage reddened bony prominence areas vigorously
C) Position pillows between the bony prominences
D) Keep the head of bed elevated at 45 degrees at all times
Answer: C) Position pillows between the bony prominences
Rationale: Placing pillows between bony prominences (such as the knees and ankles)
reduces direct pressure and friction on vulnerable skin areas, thereby decreasing the
risk of pressure ulcer development.
,3. A nurse is caring for a client who is postoperative and is receiving an IV infusion of
cefazolin. Ten minutes after beginning the infusion, the client reports intense itching.
Which of the following actions should the nurse take first?
A) Administer diphenhydramine IV
B) Notify the provider immediately
C) Slow the infusion rate
D) Stop the medication infusion
Answer: D) Stop the medication infusion
Rationale: Intense itching shortly after starting an antibiotic infusion suggests a
hypersensitivity or allergic reaction. The first priority is to stop the infusion to prevent
further exposure to the allergen and to prevent the reaction from escalating to
anaphylaxis.
4. A nurse is reinforcing teaching with a client who has gonorrhea. Which of the
following information should the nurse include?
A) The infection can be cured with a single dose of acetaminophen
B) Sexual partners do not require treatment unless they show symptoms
C) You are at risk for infertility with this infection, regardless of treatment
D) This infection provides immunity against future gonorrhea infections
Answer: C) You are at risk for infertility with this infection, regardless of treatment
Rationale: Gonorrhea can cause scarring and damage to the reproductive tract, which
may lead to infertility even after successful treatment. Clients should be counseled
about this risk to encourage follow-up care and prevention of reinfection.
, 5. A nurse is examining a client's IV site and notes a red line up his arm. The client
reports a throbbing, burning pain at the IV site. The nurse should identify that the
client's manifestations indicate which of the following complications?
A) Infiltration
B) Phlebitis
C) Thrombophlebitis
D) Extravasation
Answer: C) Thrombophlebitis
Rationale: Thrombophlebitis is characterized by inflammation of a vein with clot
formation, presenting with a red streak (red line) along the vein tract, along with
throbbing and burning pain at the IV site. The red line differentiates it from simple
phlebitis.
6. A nurse is reinforcing teaching with an adolescent client regarding testicular self-
examination. Which of the following statements by the client demonstrates an
understanding of the teaching?
A) "I should examine my testicles once a year during a warm bath."
B) "I understand that testicular cancer is painless."
C) "I should report any smooth, firm areas to my doctor."
D) "Hard lumps are usually normal and nothing to worry about."
Answer: B) "I understand that testicular cancer is painless."
Rationale: Testicular cancer is typically painless in its early stages. Educating the
client that a painless lump or mass warrants immediate medical evaluation is key to
early detection and improved outcomes.
