ATI RN Adult Medical-Surgical NGN Proctored Exam
2026–2027 | Verified Questions & Answers | Clinical
Judgment Study Guide | Graded A+
1. A nurse auscultates a new S3 heart sound in a client with a history of heart failure who
reports increasing dyspnea. Which of the following actions should the nurse take first?
A. Notify the provider of the new finding
B. Obtain a daily weight
C. Place the client on bedrest
D. Request a low-sodium diet tray
Answer: A. An S3 gallop indicates fluid overload and worsening heart failure, requiring
prompt provider notification for diuretic adjustment or further evaluation.
2. A nurse observes a client aspirate thin liquids during oral intake assessment. Which of
the following actions should the nurse take first to prevent further complications?
A. Turn the client to the left side and maintain the position
B. Perform a blind finger sweep of the oropharynx
C. Suction the oral airway
D. Activate the emergency code team
Answer: A. Placing the client in the left lateral position uses gravity to keep aspirated
material from entering the right mainstem bronchus and promotes drainage.
3. A nurse discovers that an unlicensed assistive personnel administered over-the-counter
medications to a client without authorization. Which of the following actions should the
nurse take to address the scope-of-practice violation?
A. Provide immediate retraining on delegation guidelines and document the
incident
B. Terminate the UAP from the unit
C. Ignore the incident if the client is stable
D. Hold the LPN accountable for supervision failure
Answer: A. Education and documentation promote accountability, reinforce safe
practices, and prevent recurrence without punitive measures.
4. A nurse is reviewing magnesium laboratory results for a client receiving furosemide for
heart failure, which show a serum magnesium level of 1.2 mg/dL (normal 1.7 to 2.2
mg/dL). Which of the following clinical manifestations should the nurse expect to
assess?
A. Constipation and abdominal distention
B. Muscle tremors and positive Trousseau's sign
C. Hypertension and tachycardia
D. Bradycardia and hypotension
Answer: B. Hypomagnesemia causes neuromuscular excitability, leading to tremors,
tetany, and positive Chvostek's or Trousseau's signs.
,5. A nurse is assessing the sternal incision site of a client 2 days postoperative coronary
artery bypass graft surgery and notes redness, warmth, and purulent drainage. Which of
the following actions should the nurse take first?
A. Obtain a wound culture and sensitivity
B. Administer empiric antibiotics
C. Apply a warm heat pack
D. Continue monitoring without intervention
Answer: A. Culturing the wound identifies the causative organism and guides targeted
antibiotic therapy, preventing mediastinitis.
6. A nurse is caring for a client with a flail chest segment following a motor vehicle crash.
Which of the following ventilatory support measures should the nurse implement first?
A. Manually stabilize the flail segment with a bulky dressing and tape
B. Initiate bag-valve-mask ventilation
C. Prepare for endotracheal intubation
D. Insert a chest tube for pneumothorax
Answer: A. Manual stabilization reduces paradoxical chest wall movement, improving
ventilation and oxygenation immediately.
7. A nurse suspects opioid overdose in a postoperative client exhibiting pinpoint pupils,
respiratory rate 8/min, and sedation. Which of the following medications should the nurse
prepare to administer?
A. Naloxone 0.4 mg intravenously
B. Flumazenil 0.2 mg intravenously
C. Atropine 0.5 mg intravenously
D. Epinephrine 0.3 mg intramuscularly
Answer: A. Naloxone is the specific opioid antagonist that rapidly reverses respiratory
depression and sedation.
8. The medical-surgical unit is short-staffed during a shift change. As the charge nurse
demonstrates effective leadership, which of the following client assignments reflects
appropriate prioritization?
A. Assign an LPN to care for the client with acute respiratory failure requiring frequent
assessments
B. Assign the registered nurse with the most experience to the client with multiple
organ dysfunction
C. Assign the UAP to administer oral medications
D. Assign all stable clients to one registered nurse
Answer: B. The most experienced registered nurse should manage the highest-acuity
client to ensure safe clinical judgment and decision-making.
9. A nurse is monitoring a client with diabetic ketoacidosis receiving an insulin drip. The
client's blood glucose drops from 450 mg/dL to 85 mg/dL. Which of the following actions
should the nurse take first?
A. Stop the insulin infusion and administer a 50% dextrose bolus
B. Continue the infusion at half rate
C. Notify the provider for new orders
D. Increase the intravenous fluid rate
, Answer: A. Rapid hypoglycemia requires immediate discontinuation of insulin and
glucose administration to prevent cerebral effects.
10.A client with chronic renal failure on hemodialysis reports severe itching and has
laboratory results showing serum phosphorus 6.8 mg/dL. Which dietary intervention
should the nurse prioritize in teaching?
A. Restrict intake of phosphorus-rich foods such as dairy, nuts, and cola
B. Increase consumption of high-potassium fruits
C. Encourage high-protein meals daily
D. Promote unlimited fluid intake
Answer: A. Hyperphosphatemia exacerbates pruritus and secondary
hyperparathyroidism; binding and dietary restriction are essential.
11.A nurse is delegating tasks and instructs an LPN to monitor a client receiving continuous
bladder irrigation after transurethral resection of the prostate. Which finding reported by
the LPN requires the registered nurse's immediate intervention?
A. Bright red urine output exceeding 100 mL/hr
B. Clear yellow irrigation fluid
C. Clots smaller than a quarter
D. Catheter patency confirmed
Answer: A. Excessive hematuria suggests bladder perforation or bleeding, necessitating
irrigation stoppage and provider notification.
12.During handoff report, the oncoming nurse learns of a client with suspected pulmonary
embolism who has sudden dyspnea and pleuritic chest pain. Which assessment finding
should prompt immediate escalation?
A. Heart rate 130/min and SpO2 88% on 4 L oxygen
B. Temperature 37.8°C
C. Urine output 50 mL/hr
D. Blood pressure 132/80 mm Hg
Answer: A. Tachycardia with refractory hypoxemia indicates hemodynamic instability,
requiring rapid response team activation.
13.A nurse is preparing to witness a blood transfusion and verifies the unit with another
registered nurse. The client has a history of allergic reactions. Which of the following
baseline assessments is priority before starting?
A. Vital signs and confirmation of no transfusion reactions
B. Height and weight
C. Pain level
D. Bowel sounds
Answer: A. Baseline vital signs allow detection of transfusion reactions such as fever or
hypotension within the first 15 minutes.
14.A client postoperative day 1 after abdominal surgery develops tachycardia to 118/min,
hypotension to 90/60 mm Hg, and cool clammy skin. Which of the following nursing
diagnoses reflects the priority clinical judgment?
A. Ineffective tissue perfusion related to hypovolemia
B. Acute pain related to surgical incision
C. Impaired gas exchange related to atelectasis
2026–2027 | Verified Questions & Answers | Clinical
Judgment Study Guide | Graded A+
1. A nurse auscultates a new S3 heart sound in a client with a history of heart failure who
reports increasing dyspnea. Which of the following actions should the nurse take first?
A. Notify the provider of the new finding
B. Obtain a daily weight
C. Place the client on bedrest
D. Request a low-sodium diet tray
Answer: A. An S3 gallop indicates fluid overload and worsening heart failure, requiring
prompt provider notification for diuretic adjustment or further evaluation.
2. A nurse observes a client aspirate thin liquids during oral intake assessment. Which of
the following actions should the nurse take first to prevent further complications?
A. Turn the client to the left side and maintain the position
B. Perform a blind finger sweep of the oropharynx
C. Suction the oral airway
D. Activate the emergency code team
Answer: A. Placing the client in the left lateral position uses gravity to keep aspirated
material from entering the right mainstem bronchus and promotes drainage.
3. A nurse discovers that an unlicensed assistive personnel administered over-the-counter
medications to a client without authorization. Which of the following actions should the
nurse take to address the scope-of-practice violation?
A. Provide immediate retraining on delegation guidelines and document the
incident
B. Terminate the UAP from the unit
C. Ignore the incident if the client is stable
D. Hold the LPN accountable for supervision failure
Answer: A. Education and documentation promote accountability, reinforce safe
practices, and prevent recurrence without punitive measures.
4. A nurse is reviewing magnesium laboratory results for a client receiving furosemide for
heart failure, which show a serum magnesium level of 1.2 mg/dL (normal 1.7 to 2.2
mg/dL). Which of the following clinical manifestations should the nurse expect to
assess?
A. Constipation and abdominal distention
B. Muscle tremors and positive Trousseau's sign
C. Hypertension and tachycardia
D. Bradycardia and hypotension
Answer: B. Hypomagnesemia causes neuromuscular excitability, leading to tremors,
tetany, and positive Chvostek's or Trousseau's signs.
,5. A nurse is assessing the sternal incision site of a client 2 days postoperative coronary
artery bypass graft surgery and notes redness, warmth, and purulent drainage. Which of
the following actions should the nurse take first?
A. Obtain a wound culture and sensitivity
B. Administer empiric antibiotics
C. Apply a warm heat pack
D. Continue monitoring without intervention
Answer: A. Culturing the wound identifies the causative organism and guides targeted
antibiotic therapy, preventing mediastinitis.
6. A nurse is caring for a client with a flail chest segment following a motor vehicle crash.
Which of the following ventilatory support measures should the nurse implement first?
A. Manually stabilize the flail segment with a bulky dressing and tape
B. Initiate bag-valve-mask ventilation
C. Prepare for endotracheal intubation
D. Insert a chest tube for pneumothorax
Answer: A. Manual stabilization reduces paradoxical chest wall movement, improving
ventilation and oxygenation immediately.
7. A nurse suspects opioid overdose in a postoperative client exhibiting pinpoint pupils,
respiratory rate 8/min, and sedation. Which of the following medications should the nurse
prepare to administer?
A. Naloxone 0.4 mg intravenously
B. Flumazenil 0.2 mg intravenously
C. Atropine 0.5 mg intravenously
D. Epinephrine 0.3 mg intramuscularly
Answer: A. Naloxone is the specific opioid antagonist that rapidly reverses respiratory
depression and sedation.
8. The medical-surgical unit is short-staffed during a shift change. As the charge nurse
demonstrates effective leadership, which of the following client assignments reflects
appropriate prioritization?
A. Assign an LPN to care for the client with acute respiratory failure requiring frequent
assessments
B. Assign the registered nurse with the most experience to the client with multiple
organ dysfunction
C. Assign the UAP to administer oral medications
D. Assign all stable clients to one registered nurse
Answer: B. The most experienced registered nurse should manage the highest-acuity
client to ensure safe clinical judgment and decision-making.
9. A nurse is monitoring a client with diabetic ketoacidosis receiving an insulin drip. The
client's blood glucose drops from 450 mg/dL to 85 mg/dL. Which of the following actions
should the nurse take first?
A. Stop the insulin infusion and administer a 50% dextrose bolus
B. Continue the infusion at half rate
C. Notify the provider for new orders
D. Increase the intravenous fluid rate
, Answer: A. Rapid hypoglycemia requires immediate discontinuation of insulin and
glucose administration to prevent cerebral effects.
10.A client with chronic renal failure on hemodialysis reports severe itching and has
laboratory results showing serum phosphorus 6.8 mg/dL. Which dietary intervention
should the nurse prioritize in teaching?
A. Restrict intake of phosphorus-rich foods such as dairy, nuts, and cola
B. Increase consumption of high-potassium fruits
C. Encourage high-protein meals daily
D. Promote unlimited fluid intake
Answer: A. Hyperphosphatemia exacerbates pruritus and secondary
hyperparathyroidism; binding and dietary restriction are essential.
11.A nurse is delegating tasks and instructs an LPN to monitor a client receiving continuous
bladder irrigation after transurethral resection of the prostate. Which finding reported by
the LPN requires the registered nurse's immediate intervention?
A. Bright red urine output exceeding 100 mL/hr
B. Clear yellow irrigation fluid
C. Clots smaller than a quarter
D. Catheter patency confirmed
Answer: A. Excessive hematuria suggests bladder perforation or bleeding, necessitating
irrigation stoppage and provider notification.
12.During handoff report, the oncoming nurse learns of a client with suspected pulmonary
embolism who has sudden dyspnea and pleuritic chest pain. Which assessment finding
should prompt immediate escalation?
A. Heart rate 130/min and SpO2 88% on 4 L oxygen
B. Temperature 37.8°C
C. Urine output 50 mL/hr
D. Blood pressure 132/80 mm Hg
Answer: A. Tachycardia with refractory hypoxemia indicates hemodynamic instability,
requiring rapid response team activation.
13.A nurse is preparing to witness a blood transfusion and verifies the unit with another
registered nurse. The client has a history of allergic reactions. Which of the following
baseline assessments is priority before starting?
A. Vital signs and confirmation of no transfusion reactions
B. Height and weight
C. Pain level
D. Bowel sounds
Answer: A. Baseline vital signs allow detection of transfusion reactions such as fever or
hypotension within the first 15 minutes.
14.A client postoperative day 1 after abdominal surgery develops tachycardia to 118/min,
hypotension to 90/60 mm Hg, and cool clammy skin. Which of the following nursing
diagnoses reflects the priority clinical judgment?
A. Ineffective tissue perfusion related to hypovolemia
B. Acute pain related to surgical incision
C. Impaired gas exchange related to atelectasis
