2026 ATI RN ADULT MEDICAL-SURGICAL NGN PRACTICE
EXAM
Comprehensive Next Generation NCLEX (NGN) Style Practice Exam with Clinical Judgment
Measurement Model (CJMM) Integration, Bow-Tie Items, Matrix Grids, Extended Multiple
Response, and Detailed Rationales.
Exam Overview & Instructions
This comprehensive practice exam is designed to reflect the rigorous standards of the 2026 ATI RN Adult
Medical-Surgical Nursing Proctored Assessment and the Next Generation NCLEX (NGN). The questions
incorporate the Clinical Judgment Measurement Model (CJMM), emphasizing cue recognition,
hypothesis generation, prioritization, solution generation, and outcome evaluation across complex
medical-surgical clinical scenarios.
Total Items: 100 Clinical & NGN Case Study Questions. Each question includes correct answers, thorough
rationales, and client needs category mapping.
1. A nurse is caring for a client who is 4 hr postoperative following a total knee
arthroplasty. Which of the following findings requires immediate intervention
by the nurse?
A) Serosanguineous drainage measuring 50 mL on the dressing
B) Absence of dorsalis pedis pulse in the operative extremity
C) Mild pain controlled with prescribed IV opioid medication
D) Capillary refill of 3 seconds in the unaffected extremity
Answer: Correct Answer: B
Rationale: Rationale: The absence of a distal pulse in the operative extremity indicates acute arterial
occlusion and impaired tissue perfusion, which is a surgical emergency requiring immediate provider
notification to prevent limb loss. Serosanguineous drainage (A) is expected. Mild controlled pain (C) and
normal capillary refill in the unaffected side (D) are stable findings.
2. A nurse is assessing a client who has acute respiratory distress syndrome
(ARDS) and is receiving mechanical ventilation with PEEP. Which of the
following findings indicates a potential complication of PEEP?
A) Decreased peak inspiratory pressure
B) Sudden onset of hypotension and absent breath sounds on the left side
C) Increase in arterial oxygen saturation (SaO2)
,D) Bilateral symmetrical chest wall expansion
Answer: Correct Answer: B
Rationale: Rationale: High levels of positive end-expiratory pressure (PEEP) increase intrathoracic
pressure, putting the client at significant risk for barotrauma, leading to a tension pneumothorax
characterized by sudden hypotension, tracheal deviation, and absent breath sounds on the affected
side. Decreased peak pressure (A), increased SaO2 (C), and symmetrical expansion (D) are not indicators
of barotrauma.
3. A nurse in an emergency department is caring for a client who has diabetic
ketoacidosis (DKA). Which of the following provider prescriptions should the
nurse anticipate implementing first?
A) Administer regular insulin 10 units IV bolus followed by a continuous infusion
B) Administer 0.9% sodium chloride 1,000 mL IV bolus
C) Administer sodium bicarbonate 50 mEq IV for pH < 6.9
D) Initiate a continuous infusion of regular insulin at 0.1 units/kg/hr without a bolus
Answer: Correct Answer: B
Rationale: Rationale: According to evidence-based DKA management guidelines, fluid resuscitation with
0.9% sodium chloride to restore intravascular volume and tissue perfusion is the absolute first priority
before initiating insulin therapy, as insulin can drive potassium intracellularly and worsen
hypovolemia/shock.
4. A nurse is planning care for a client who has neutropenia following
chemotherapy. Which of the following interventions should the nurse include in
the plan?
A) Monitor the client's temperature every 4 hr
B) Assign the client to a shared double-occupancy room
C) Provide fresh unpeeled fruits and raw vegetables with meals
D) Inspect oral mucous membranes every 8 hr for lesions
Answer: Correct Answer: D
Rationale: Rationale: Inspecting oral mucous membranes every 8 hr is crucial for early detection of
infection (e.g., candidiasis, mucositis) in neutropenic clients. Temperature should be monitored every 4
hr (or more frequently per protocol, but oral checks are specific protective measures). The client
requires a private room (not shared), and fresh fruits/vegetables should be avoided due to bacteria.
,5. A nurse is monitoring a client who has chronic kidney disease (CKD) and a
serum potassium level of 6.8 mEq/L. Which of the following electrocardiogram
(ECG) changes should the nurse expect to observe?
A) Prominent U waves
B) Tall, peaked T waves
C) Flattened P waves
D) Prolonged QT intervals
Answer: Correct Answer: B
Rationale: Rationale: Severe hyperkalemia (potassium > 5.0 mEq/L, and critically at 6.8 mEq/L) causes
characteristic ECG changes including tall, peaked T waves, prolonged PR intervals, widened QRS
complexes, and eventually sine waves. Prominent U waves (A) are associated with hypokalemia.
Prolonged QT intervals (D) are associated with hypocalcemia.
6. A nurse is caring for a client who is receiving total parenteral nutrition (TPN)
via a peripherally inserted central catheter (PICC) line. The TPN solution has just
run out, and the replacement bag has not yet arrived from the pharmacy. Which
of the following actions should the nurse take?
A) Infuse 0.9% sodium chloride through the PICC line
B) Infuse 10% dextrose in water through the PICC line at the same rate
C) Flush the PICC line with heparinized saline and clamp
D) Discontinue the PICC line dressing and inspect the insertion site
Answer: Correct Answer: B
Rationale: Rationale: To prevent severe rebound hypoglycemia resulting from sudden cessation of high-
dextrose TPN, the nurse must infuse 10% or 20% dextrose in water at the prescribed TPN infusion rate
until the next bag becomes available.
7. A nurse is assessing a client who has a suspected pulmonary embolism. Which
of the following is the most common classic manifestation reported by the
client?
A) Frothy pink-tinged sputum
B) Sudden onset of dyspnea and pleuritic chest pain
C) Intermittent claudication in the lower extremities
D) Bradycardia and hypertension
Answer: Correct Answer: B
, Rationale: Rationale: The hallmark clinical manifestations of a pulmonary embolism are sudden,
unexplained dyspnea accompanied by pleuritic chest pain and tachypnea. Frothy pink-tinged sputum (A)
is classic for acute pulmonary edema.
8. A nurse is providing discharge teaching to a client who has a new prescription
for warfarin following mechanical heart valve replacement. Which of the
following statements by the client indicates an understanding of the teaching?
A) 'I will increase my intake of dark green leafy vegetables like spinach.'
B) 'I should use a soft-bristled toothbrush and an electric razor.'
C) 'I can take aspirin for occasional headaches while taking warfarin.'
D) 'My target INR range will be between 1.0 and 2.0.'
Answer: Correct Answer: B
Rationale: Rationale: Using a soft toothbrush and electric razor minimizes bleeding risks associated with
anticoagulant therapy. Clients must maintain a consistent (not increased) intake of vitamin K-rich foods
(A). Aspirin increases bleeding risk and should be avoided (C). The therapeutic INR range for a
mechanical heart valve is 2.5 to 3.5 (D).
9. A nurse is caring for a client who has acute pancreatitis and reports severe,
boring epigastric pain radiating to the back. Which of the following
interventions should the nurse anticipate?
A) Initiate a clear liquid diet immediately
B) Administer prescribed anticholinergic medications
C) Maintain the client NPO and insert a nasogastric tube if vomiting is present
D) Position the client flat in the supine position
Answer: Correct Answer: C
Rationale: Rationale: Maintaining the client NPO and resting the pancreas by decompressing the GI tract
with an NG tube if nausea/vomiting is present is foundational in acute pancreatitis management. Clients
should be positioned in a side-lying or sitting position leaning forward (not flat supine) to reduce pain.
10. A nurse is assessing a client who has Cushing's syndrome due to chronic
corticosteroid therapy. Which of the following physical findings should the
nurse expect?
A) Weight loss and hypotension
B) Truncal obesity, buffalo hump, and purple striae
C) Bronze skin pigmentation and hypoglycemia
EXAM
Comprehensive Next Generation NCLEX (NGN) Style Practice Exam with Clinical Judgment
Measurement Model (CJMM) Integration, Bow-Tie Items, Matrix Grids, Extended Multiple
Response, and Detailed Rationales.
Exam Overview & Instructions
This comprehensive practice exam is designed to reflect the rigorous standards of the 2026 ATI RN Adult
Medical-Surgical Nursing Proctored Assessment and the Next Generation NCLEX (NGN). The questions
incorporate the Clinical Judgment Measurement Model (CJMM), emphasizing cue recognition,
hypothesis generation, prioritization, solution generation, and outcome evaluation across complex
medical-surgical clinical scenarios.
Total Items: 100 Clinical & NGN Case Study Questions. Each question includes correct answers, thorough
rationales, and client needs category mapping.
1. A nurse is caring for a client who is 4 hr postoperative following a total knee
arthroplasty. Which of the following findings requires immediate intervention
by the nurse?
A) Serosanguineous drainage measuring 50 mL on the dressing
B) Absence of dorsalis pedis pulse in the operative extremity
C) Mild pain controlled with prescribed IV opioid medication
D) Capillary refill of 3 seconds in the unaffected extremity
Answer: Correct Answer: B
Rationale: Rationale: The absence of a distal pulse in the operative extremity indicates acute arterial
occlusion and impaired tissue perfusion, which is a surgical emergency requiring immediate provider
notification to prevent limb loss. Serosanguineous drainage (A) is expected. Mild controlled pain (C) and
normal capillary refill in the unaffected side (D) are stable findings.
2. A nurse is assessing a client who has acute respiratory distress syndrome
(ARDS) and is receiving mechanical ventilation with PEEP. Which of the
following findings indicates a potential complication of PEEP?
A) Decreased peak inspiratory pressure
B) Sudden onset of hypotension and absent breath sounds on the left side
C) Increase in arterial oxygen saturation (SaO2)
,D) Bilateral symmetrical chest wall expansion
Answer: Correct Answer: B
Rationale: Rationale: High levels of positive end-expiratory pressure (PEEP) increase intrathoracic
pressure, putting the client at significant risk for barotrauma, leading to a tension pneumothorax
characterized by sudden hypotension, tracheal deviation, and absent breath sounds on the affected
side. Decreased peak pressure (A), increased SaO2 (C), and symmetrical expansion (D) are not indicators
of barotrauma.
3. A nurse in an emergency department is caring for a client who has diabetic
ketoacidosis (DKA). Which of the following provider prescriptions should the
nurse anticipate implementing first?
A) Administer regular insulin 10 units IV bolus followed by a continuous infusion
B) Administer 0.9% sodium chloride 1,000 mL IV bolus
C) Administer sodium bicarbonate 50 mEq IV for pH < 6.9
D) Initiate a continuous infusion of regular insulin at 0.1 units/kg/hr without a bolus
Answer: Correct Answer: B
Rationale: Rationale: According to evidence-based DKA management guidelines, fluid resuscitation with
0.9% sodium chloride to restore intravascular volume and tissue perfusion is the absolute first priority
before initiating insulin therapy, as insulin can drive potassium intracellularly and worsen
hypovolemia/shock.
4. A nurse is planning care for a client who has neutropenia following
chemotherapy. Which of the following interventions should the nurse include in
the plan?
A) Monitor the client's temperature every 4 hr
B) Assign the client to a shared double-occupancy room
C) Provide fresh unpeeled fruits and raw vegetables with meals
D) Inspect oral mucous membranes every 8 hr for lesions
Answer: Correct Answer: D
Rationale: Rationale: Inspecting oral mucous membranes every 8 hr is crucial for early detection of
infection (e.g., candidiasis, mucositis) in neutropenic clients. Temperature should be monitored every 4
hr (or more frequently per protocol, but oral checks are specific protective measures). The client
requires a private room (not shared), and fresh fruits/vegetables should be avoided due to bacteria.
,5. A nurse is monitoring a client who has chronic kidney disease (CKD) and a
serum potassium level of 6.8 mEq/L. Which of the following electrocardiogram
(ECG) changes should the nurse expect to observe?
A) Prominent U waves
B) Tall, peaked T waves
C) Flattened P waves
D) Prolonged QT intervals
Answer: Correct Answer: B
Rationale: Rationale: Severe hyperkalemia (potassium > 5.0 mEq/L, and critically at 6.8 mEq/L) causes
characteristic ECG changes including tall, peaked T waves, prolonged PR intervals, widened QRS
complexes, and eventually sine waves. Prominent U waves (A) are associated with hypokalemia.
Prolonged QT intervals (D) are associated with hypocalcemia.
6. A nurse is caring for a client who is receiving total parenteral nutrition (TPN)
via a peripherally inserted central catheter (PICC) line. The TPN solution has just
run out, and the replacement bag has not yet arrived from the pharmacy. Which
of the following actions should the nurse take?
A) Infuse 0.9% sodium chloride through the PICC line
B) Infuse 10% dextrose in water through the PICC line at the same rate
C) Flush the PICC line with heparinized saline and clamp
D) Discontinue the PICC line dressing and inspect the insertion site
Answer: Correct Answer: B
Rationale: Rationale: To prevent severe rebound hypoglycemia resulting from sudden cessation of high-
dextrose TPN, the nurse must infuse 10% or 20% dextrose in water at the prescribed TPN infusion rate
until the next bag becomes available.
7. A nurse is assessing a client who has a suspected pulmonary embolism. Which
of the following is the most common classic manifestation reported by the
client?
A) Frothy pink-tinged sputum
B) Sudden onset of dyspnea and pleuritic chest pain
C) Intermittent claudication in the lower extremities
D) Bradycardia and hypertension
Answer: Correct Answer: B
, Rationale: Rationale: The hallmark clinical manifestations of a pulmonary embolism are sudden,
unexplained dyspnea accompanied by pleuritic chest pain and tachypnea. Frothy pink-tinged sputum (A)
is classic for acute pulmonary edema.
8. A nurse is providing discharge teaching to a client who has a new prescription
for warfarin following mechanical heart valve replacement. Which of the
following statements by the client indicates an understanding of the teaching?
A) 'I will increase my intake of dark green leafy vegetables like spinach.'
B) 'I should use a soft-bristled toothbrush and an electric razor.'
C) 'I can take aspirin for occasional headaches while taking warfarin.'
D) 'My target INR range will be between 1.0 and 2.0.'
Answer: Correct Answer: B
Rationale: Rationale: Using a soft toothbrush and electric razor minimizes bleeding risks associated with
anticoagulant therapy. Clients must maintain a consistent (not increased) intake of vitamin K-rich foods
(A). Aspirin increases bleeding risk and should be avoided (C). The therapeutic INR range for a
mechanical heart valve is 2.5 to 3.5 (D).
9. A nurse is caring for a client who has acute pancreatitis and reports severe,
boring epigastric pain radiating to the back. Which of the following
interventions should the nurse anticipate?
A) Initiate a clear liquid diet immediately
B) Administer prescribed anticholinergic medications
C) Maintain the client NPO and insert a nasogastric tube if vomiting is present
D) Position the client flat in the supine position
Answer: Correct Answer: C
Rationale: Rationale: Maintaining the client NPO and resting the pancreas by decompressing the GI tract
with an NG tube if nausea/vomiting is present is foundational in acute pancreatitis management. Clients
should be positioned in a side-lying or sitting position leaning forward (not flat supine) to reduce pain.
10. A nurse is assessing a client who has Cushing's syndrome due to chronic
corticosteroid therapy. Which of the following physical findings should the
nurse expect?
A) Weight loss and hypotension
B) Truncal obesity, buffalo hump, and purple striae
C) Bronze skin pigmentation and hypoglycemia
