ATI RN Adult Medical-Surgical (Med-Surg) 2026 Proctored
Examination with NGN - Version 3.1
Advanced Clinical Judgment and Critical Reasoning Assessment: A
Comprehensive 100-Question Examination Featuring Complex Multi-
System Presentations, Pharmacological Nuances, Prioritization
Frameworks, and Next Generation NCLEX-Style Clinical Judgment
Scenarios for Senior Nursing Students, Graduate Nurses, and
Professional Certification Candidates
Instructions:
Each question has one correct answer unless otherwise specified.
Select the best answer based on current evidence-based practice, ATI testing standards, and the
most recent clinical guidelines.
Questions incorporate Next Generation NCLEX (NGN) clinical judgment frameworks including
prioritization, delegation, and clinical reasoning.
Some questions require synthesis of multiple data points and application of the nursing process.
Cardiovascular Disorders
Question 1
A 68-year-old client with a history of hypertension, type 2 diabetes mellitus, and chronic kidney
disease stage III is admitted with acute decompensated heart failure (ADHF). The client is receiving IV
furosemide 80 mg BID and is on a 2-gram sodium-restricted diet. The nurse notes the client's urine
output has been 150 mL over the past 4 hours, blood pressure is 158/92 mm Hg, heart rate is 102
bpm, respiratory rate is 28 breaths/min, oxygen saturation is 89% on 2 L/min nasal cannula, and the
client has new-onset confusion. Which intervention should the nurse implement FIRST?
A. Increase the furosemide infusion rate as prescribed
, B. Administer 3% hypertonic saline IV push
C. Notify the healthcare provider for possible BIPAP initiation
D. Administer IV metoprolol 5 mg slow IV push
Correct Answer: C. Notify the healthcare provider for possible BIPAP initiation
Rationale: This client is exhibiting signs of acute respiratory failure with hypoxemia (SpO2 89%),
tachypnea (28), tachycardia (102), hypertension (158/92), confusion, and oliguria indicating worsening
ADHF with possible cardiogenic shock and impending respiratory failure. The priority is to improve
oxygenation and ventilation. Non-invasive positive pressure ventilation (BIPAP) can reduce preload and
afterload, improve cardiac output, and prevent intubation. Increasing furosemide alone will not
address the acute respiratory failure. Hypertonic saline would worsen fluid overload. Metoprolol is
contraindicated in acute decompensated HF with pulmonary edema.
Question 2
A 72-year-old client with atrial fibrillation is prescribed apixaban 5 mg BID for stroke prevention. The
client also takes amlodipine 10 mg daily for hypertension, metformin 1000 mg BID for type 2 diabetes,
and omeprazole 20 mg daily for GERD. The client is scheduled for a colonoscopy in 2 weeks. Which
instruction should the nurse provide regarding the apixaban?
A. "Continue taking apixaban as prescribed; it does not affect the procedure."
B. "Discontinue apixaban 24 hours before the procedure and resume 24 hours after."
C. "Discontinue apixaban 5 days before the procedure and resume 48 hours after."
D. "Discontinue apixaban 7 days before the procedure and resume 72 hours after."
Correct Answer: B. "Discontinue apixaban 24 hours before the procedure and resume 24 hours after."
Rationale: Apixaban is a direct oral anticoagulant (DOAC) with a half-life of approximately 12 hours.
For procedures with low bleeding risk, the recommendation is to hold for 24 hours before the
procedure and resume 24 hours after, assuming hemostasis is achieved. For procedures with high
bleeding risk, hold for 48 hours. Colonoscopy with biopsy is considered moderate risk; 24 hours is
appropriate. Holding for 5-7 days would unnecessarily increase stroke risk. The client's other
medications (amlodipine, metformin, omeprazole) do not interact significantly with apixaban.
,Question 3
A client is 12 hours post-percutaneous coronary intervention (PCI) with drug-eluting stents placed in
the left anterior descending (LAD) and right coronary arteries (RCA). The client is receiving dual
antiplatelet therapy (DAPT) with aspirin 81 mg daily and ticagrelor 90 mg BID. The client's morning
laboratory results show hemoglobin 9.2 g/dL (baseline 12.8 g/dL), hematocrit 27.6%, and platelet
count 198,000/mm³. The client reports mild chest discomfort rated 3/10 and is slightly diaphoretic.
Which action should the nurse take FIRST?
A. Administer the prescribed aspirin and ticagrelor immediately
B. Obtain a STAT 12-lead ECG
C. Notify the healthcare provider of the drop in hemoglobin
D. Administer IV morphine 2 mg for chest discomfort
Correct Answer: B. Obtain a STAT 12-lead ECG
Rationale: The client's chest discomfort, diaphoresis, and significant drop in hemoglobin (3.6 g/dL
drop over 12 hours) in the setting of recent PCI with DAPT raises concern for possible acute stent
thrombosis or bleeding complications (retroperitoneal bleed, coronary perforation). The priority is to
obtain a STAT ECG to evaluate for ischemic changes (ST-segment elevation or depression) indicative of
stent thrombosis. While the hemoglobin drop is concerning and requires notification, the ECG should
be obtained first to guide immediate management. Holding DAPT is not indicated without evidence of
significant bleeding. Morphine may mask symptoms and delay diagnosis.
Question 4
A 65-year-old client with severe aortic stenosis is scheduled for transcatheter aortic valve replacement
(TAVR) in 2 weeks. The client has a history of chronic kidney disease (eGFR 35 mL/min/1.73m²),
hypertension, and hypothyroidism. Which pre-procedural assessment finding should the nurse report
to the healthcare provider PRIOR to the procedure?
A. Serum creatinine 2.0 mg/dL
B. TSH 4.5 mIU/L
C. Blood pressure 148/86 mm Hg
D. Temperature 100.8°F (38.2°C) with chills
, Correct Answer: D. Temperature 100.8°F (38.2°C) with chills
Rationale: Fever with chills in a client with severe aortic stenosis raises concern for infective
endocarditis, which is a contraindication to TAVR and requires treatment before the procedure. The
presence of infection increases the risk of prosthetic valve infection and mortality. The eGFR of 35
mL/min is an expected finding in CKD and is not a contraindication to TAVR (though contrast-induced
nephropathy risk exists). TSH 4.5 mIU/L is within normal limits (though some labs consider it borderline
high). Blood pressure 148/86 is not optimally controlled but does not preclude TAVR.
Question 5
A client with hypertrophic cardiomyopathy (HCM) is experiencing exertional chest pain and dyspnea.
The client is prescribed verapamil. The nurse should monitor for which potential complication of this
medication?
A. Worsening of left ventricular outflow tract obstruction
B. Bradycardia and heart block
C. Hypertension and tachycardia
D. Pulmonary edema
Correct Answer: B. Bradycardia and heart block
Rationale: Verapamil is a calcium channel blocker used to reduce myocardial contractility, slow heart
rate, and improve diastolic filling in HCM. However, it can cause bradycardia and heart block,
especially in clients with underlying conduction abnormalities. It does NOT worsen LVOT obstruction (it
may actually improve it by reducing hypercontractility). Verapamil causes hypotension, not
hypertension, and can exacerbate heart failure but is not its primary complication. Tachycardia is not a
typical effect.
Question 6
A nurse is caring for a client with an acute myocardial infarction (MI) who is receiving alteplase (tPA)
for thrombolytic therapy. Which finding indicates the therapy is contraindicated or requires holding?
A. Chest pain rated 8/10
Examination with NGN - Version 3.1
Advanced Clinical Judgment and Critical Reasoning Assessment: A
Comprehensive 100-Question Examination Featuring Complex Multi-
System Presentations, Pharmacological Nuances, Prioritization
Frameworks, and Next Generation NCLEX-Style Clinical Judgment
Scenarios for Senior Nursing Students, Graduate Nurses, and
Professional Certification Candidates
Instructions:
Each question has one correct answer unless otherwise specified.
Select the best answer based on current evidence-based practice, ATI testing standards, and the
most recent clinical guidelines.
Questions incorporate Next Generation NCLEX (NGN) clinical judgment frameworks including
prioritization, delegation, and clinical reasoning.
Some questions require synthesis of multiple data points and application of the nursing process.
Cardiovascular Disorders
Question 1
A 68-year-old client with a history of hypertension, type 2 diabetes mellitus, and chronic kidney
disease stage III is admitted with acute decompensated heart failure (ADHF). The client is receiving IV
furosemide 80 mg BID and is on a 2-gram sodium-restricted diet. The nurse notes the client's urine
output has been 150 mL over the past 4 hours, blood pressure is 158/92 mm Hg, heart rate is 102
bpm, respiratory rate is 28 breaths/min, oxygen saturation is 89% on 2 L/min nasal cannula, and the
client has new-onset confusion. Which intervention should the nurse implement FIRST?
A. Increase the furosemide infusion rate as prescribed
, B. Administer 3% hypertonic saline IV push
C. Notify the healthcare provider for possible BIPAP initiation
D. Administer IV metoprolol 5 mg slow IV push
Correct Answer: C. Notify the healthcare provider for possible BIPAP initiation
Rationale: This client is exhibiting signs of acute respiratory failure with hypoxemia (SpO2 89%),
tachypnea (28), tachycardia (102), hypertension (158/92), confusion, and oliguria indicating worsening
ADHF with possible cardiogenic shock and impending respiratory failure. The priority is to improve
oxygenation and ventilation. Non-invasive positive pressure ventilation (BIPAP) can reduce preload and
afterload, improve cardiac output, and prevent intubation. Increasing furosemide alone will not
address the acute respiratory failure. Hypertonic saline would worsen fluid overload. Metoprolol is
contraindicated in acute decompensated HF with pulmonary edema.
Question 2
A 72-year-old client with atrial fibrillation is prescribed apixaban 5 mg BID for stroke prevention. The
client also takes amlodipine 10 mg daily for hypertension, metformin 1000 mg BID for type 2 diabetes,
and omeprazole 20 mg daily for GERD. The client is scheduled for a colonoscopy in 2 weeks. Which
instruction should the nurse provide regarding the apixaban?
A. "Continue taking apixaban as prescribed; it does not affect the procedure."
B. "Discontinue apixaban 24 hours before the procedure and resume 24 hours after."
C. "Discontinue apixaban 5 days before the procedure and resume 48 hours after."
D. "Discontinue apixaban 7 days before the procedure and resume 72 hours after."
Correct Answer: B. "Discontinue apixaban 24 hours before the procedure and resume 24 hours after."
Rationale: Apixaban is a direct oral anticoagulant (DOAC) with a half-life of approximately 12 hours.
For procedures with low bleeding risk, the recommendation is to hold for 24 hours before the
procedure and resume 24 hours after, assuming hemostasis is achieved. For procedures with high
bleeding risk, hold for 48 hours. Colonoscopy with biopsy is considered moderate risk; 24 hours is
appropriate. Holding for 5-7 days would unnecessarily increase stroke risk. The client's other
medications (amlodipine, metformin, omeprazole) do not interact significantly with apixaban.
,Question 3
A client is 12 hours post-percutaneous coronary intervention (PCI) with drug-eluting stents placed in
the left anterior descending (LAD) and right coronary arteries (RCA). The client is receiving dual
antiplatelet therapy (DAPT) with aspirin 81 mg daily and ticagrelor 90 mg BID. The client's morning
laboratory results show hemoglobin 9.2 g/dL (baseline 12.8 g/dL), hematocrit 27.6%, and platelet
count 198,000/mm³. The client reports mild chest discomfort rated 3/10 and is slightly diaphoretic.
Which action should the nurse take FIRST?
A. Administer the prescribed aspirin and ticagrelor immediately
B. Obtain a STAT 12-lead ECG
C. Notify the healthcare provider of the drop in hemoglobin
D. Administer IV morphine 2 mg for chest discomfort
Correct Answer: B. Obtain a STAT 12-lead ECG
Rationale: The client's chest discomfort, diaphoresis, and significant drop in hemoglobin (3.6 g/dL
drop over 12 hours) in the setting of recent PCI with DAPT raises concern for possible acute stent
thrombosis or bleeding complications (retroperitoneal bleed, coronary perforation). The priority is to
obtain a STAT ECG to evaluate for ischemic changes (ST-segment elevation or depression) indicative of
stent thrombosis. While the hemoglobin drop is concerning and requires notification, the ECG should
be obtained first to guide immediate management. Holding DAPT is not indicated without evidence of
significant bleeding. Morphine may mask symptoms and delay diagnosis.
Question 4
A 65-year-old client with severe aortic stenosis is scheduled for transcatheter aortic valve replacement
(TAVR) in 2 weeks. The client has a history of chronic kidney disease (eGFR 35 mL/min/1.73m²),
hypertension, and hypothyroidism. Which pre-procedural assessment finding should the nurse report
to the healthcare provider PRIOR to the procedure?
A. Serum creatinine 2.0 mg/dL
B. TSH 4.5 mIU/L
C. Blood pressure 148/86 mm Hg
D. Temperature 100.8°F (38.2°C) with chills
, Correct Answer: D. Temperature 100.8°F (38.2°C) with chills
Rationale: Fever with chills in a client with severe aortic stenosis raises concern for infective
endocarditis, which is a contraindication to TAVR and requires treatment before the procedure. The
presence of infection increases the risk of prosthetic valve infection and mortality. The eGFR of 35
mL/min is an expected finding in CKD and is not a contraindication to TAVR (though contrast-induced
nephropathy risk exists). TSH 4.5 mIU/L is within normal limits (though some labs consider it borderline
high). Blood pressure 148/86 is not optimally controlled but does not preclude TAVR.
Question 5
A client with hypertrophic cardiomyopathy (HCM) is experiencing exertional chest pain and dyspnea.
The client is prescribed verapamil. The nurse should monitor for which potential complication of this
medication?
A. Worsening of left ventricular outflow tract obstruction
B. Bradycardia and heart block
C. Hypertension and tachycardia
D. Pulmonary edema
Correct Answer: B. Bradycardia and heart block
Rationale: Verapamil is a calcium channel blocker used to reduce myocardial contractility, slow heart
rate, and improve diastolic filling in HCM. However, it can cause bradycardia and heart block,
especially in clients with underlying conduction abnormalities. It does NOT worsen LVOT obstruction (it
may actually improve it by reducing hypercontractility). Verapamil causes hypotension, not
hypertension, and can exacerbate heart failure but is not its primary complication. Tachycardia is not a
typical effect.
Question 6
A nurse is caring for a client with an acute myocardial infarction (MI) who is receiving alteplase (tPA)
for thrombolytic therapy. Which finding indicates the therapy is contraindicated or requires holding?
A. Chest pain rated 8/10
