NGN ATI Comprehensive Exit Retake
Exam Test Bank Versions 1–4 | 180
Questions & Answers per Exam |
NCLEX Prep Guide
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### Question 1 (NGN — Prioritization)
A nurse is caring for four clients. Which client should the nurse assess first?
A) Client with COPD and SpO₂ of 89% on 2L nasal cannula
B) Client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C) Client with heart failure and 3+ pitting edema
D) Client with new-onset confusion and a bounding pulse
,💫ANSWER✔️✔️: D
💫RATIONALE✔️✔️: New-onset confusion with a bounding pulse suggests increased intracranial
pressure, hypercapnia, or fluid overload affecting cerebral perfusion. A change in neurological status is
always the priority over chronic or expected findings .
---
### Question 2 (NGN — Delegation)
A charge nurse is assigning staff. Which client is most appropriate to assign to the Licensed Practical
Nurse (LPN)?
A) Client 1 hour post-cardiac catheterization with bleeding at the site
B) Client with stable diabetes requiring insulin administration and foot care
C) Client newly admitted with stroke and altered mental status
D) Client receiving IV heparin with a PTT of 98 seconds
💫ANSWER✔️✔️: B
💫RATIONALE✔️✔️: LPNs can administer medications (including insulin) and perform stable, routine
wound care for clients with predictable outcomes. Options A, C, and D require initial assessment, critical
lab monitoring, or management of unstable conditions, which are the responsibility of the RN .
---
### Question 3 (NGN — Delegation to UAP)
A nurse on a med-surg unit has received change-of-shift report and will care for four clients. Which of
the following client needs will the nurse assign to an AP (UAP)?
, A) Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B) Reinforcing teaching with a client who is learning to walk with a quad cane
C) Reapplying a condom catheter for a client who has urinary incontinence
D) Applying a sterile dressing to a pressure ulcer
💫ANSWER✔️✔️: C
💫RATIONALE✔️✔️: Reapplying a condom catheter is a routine task that can be delegated to AP.
Feeding a client with aspiration pneumonia requires nursing judgment (risk for aspiration); reinforcing
teaching and sterile dressing changes require licensed nursing skills .
---
### Question 4 (NGN — Delegation of Ambulation)
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which
information should the nurse share with the AP? (Select all that apply.)
A) The roommate is up independently
B) The client ambulates with his slippers on over his antiembolic stockings
C) The client uses a front-wheeled walker when ambulating
D) The client had pain meds 30 minutes ago
E) The client is allergic to codeine
F) The client ate 50% of his breakfast this morning
💫ANSWER✔️✔️: B, C, D
Exam Test Bank Versions 1–4 | 180
Questions & Answers per Exam |
NCLEX Prep Guide
---
### Question 1 (NGN — Prioritization)
A nurse is caring for four clients. Which client should the nurse assess first?
A) Client with COPD and SpO₂ of 89% on 2L nasal cannula
B) Client post-appendectomy day 2 with temperature of 38.3°C (101°F)
C) Client with heart failure and 3+ pitting edema
D) Client with new-onset confusion and a bounding pulse
,💫ANSWER✔️✔️: D
💫RATIONALE✔️✔️: New-onset confusion with a bounding pulse suggests increased intracranial
pressure, hypercapnia, or fluid overload affecting cerebral perfusion. A change in neurological status is
always the priority over chronic or expected findings .
---
### Question 2 (NGN — Delegation)
A charge nurse is assigning staff. Which client is most appropriate to assign to the Licensed Practical
Nurse (LPN)?
A) Client 1 hour post-cardiac catheterization with bleeding at the site
B) Client with stable diabetes requiring insulin administration and foot care
C) Client newly admitted with stroke and altered mental status
D) Client receiving IV heparin with a PTT of 98 seconds
💫ANSWER✔️✔️: B
💫RATIONALE✔️✔️: LPNs can administer medications (including insulin) and perform stable, routine
wound care for clients with predictable outcomes. Options A, C, and D require initial assessment, critical
lab monitoring, or management of unstable conditions, which are the responsibility of the RN .
---
### Question 3 (NGN — Delegation to UAP)
A nurse on a med-surg unit has received change-of-shift report and will care for four clients. Which of
the following client needs will the nurse assign to an AP (UAP)?
, A) Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B) Reinforcing teaching with a client who is learning to walk with a quad cane
C) Reapplying a condom catheter for a client who has urinary incontinence
D) Applying a sterile dressing to a pressure ulcer
💫ANSWER✔️✔️: C
💫RATIONALE✔️✔️: Reapplying a condom catheter is a routine task that can be delegated to AP.
Feeding a client with aspiration pneumonia requires nursing judgment (risk for aspiration); reinforcing
teaching and sterile dressing changes require licensed nursing skills .
---
### Question 4 (NGN — Delegation of Ambulation)
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which
information should the nurse share with the AP? (Select all that apply.)
A) The roommate is up independently
B) The client ambulates with his slippers on over his antiembolic stockings
C) The client uses a front-wheeled walker when ambulating
D) The client had pain meds 30 minutes ago
E) The client is allergic to codeine
F) The client ate 50% of his breakfast this morning
💫ANSWER✔️✔️: B, C, D
