ATI MED SURG PROCTORED WITH NGN EXAM LATEST
VERSION 2026-2027 EXAM WITH ACTUAL 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES.
A nurse in an emergency department is preparing to perform ocular irrigation for
a client. Which of the following actions should the nurse plan to take?
A) Assess the client's visual acuity prior to irrigation
B) Have the client turn their head toward the unaffected eye
C) Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
D) Perform the irrigation with sterile water for irrigation
Correct Answer: D
Rationale
Sterile water or sterile normal saline is the appropriate irrigation solution for
ocular irrigation. The nurse should use sterile technique to prevent infection and
ensure the safety of the procedure. Option A is incorrect because visual acuity
assessment should be performed after irrigation, not before, to evaluate the
effectiveness of the treatment and the client's eye function. Option B is incorrect
because the client should turn their head toward the affected eye to allow the
irrigating solution to flow from the inner canthus to the outer canthus, preventing
contamination of the unaffected eye. Option C is incorrect because the irrigator
syringe should be held 2.5 to 5 cm (1 to 2 inches) above the eye, not 3.81 cm
specifically, to provide adequate flow without causing trauma.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
A nurse is preparing to administer lactated Ringer's via continuous IV infusion at
200 mL/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min
should the nurse set the IV pump to administer? (Round to the nearest whole
number.)
,Correct Answer: 33 gtt/min
Rationale
To calculate the drip rate in drops per minute, use the formula: (Volume in mL ×
Drop factor) ÷ Time in minutes. The calculation is: (200 mL × 10 drops/mL) ÷ 60
minutes = 2000 ÷ 60 = 33.33 drops/min, which rounds to 33 gtt/min. The nurse
should set the IV pump to deliver 33 drops per minute. This calculation ensures
accurate fluid administration and prevents complications of underhydration or
fluid overload.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
A) "I can keep my medication for 1 year before replacing it"
B) "I should lie down when I take this medication"
C) "I should discontinue this medication if I develop a headache"
D) "I can take up to five tablets in 15 minutes before seeking medical attention"
Correct Answer: B
Rationale
The client should lie down when taking sublingual nitroglycerin to minimize the
risk of orthostatic hypotension and syncope, which are common side effects of the
medication's vasodilatory effects. Option A is incorrect because nitroglycerin
should be replaced every 6 months to maintain potency; the medication is
sensitive to light, heat, and moisture. Option C is incorrect because headache is a
common side effect of nitroglycerin due to vasodilation and does not warrant
discontinuation; the client should be advised that headaches often diminish with
continued use. Option D is incorrect because the client should take up to three
tablets, 5 minutes apart, and seek emergency care if pain persists after three
tablets.
,DIF: Cognitive Level: Evaluate (Evaluation)
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
A nurse is providing discharge teaching to an older adult client following a left
total hip arthroplasty. Which of the following instructions should the nurse include
in the teaching?
A) Clean the incision daily with hydrogen peroxide
B) You can cross your legs at the ankles when sitting down
C) You should use an incentive spirometer every 8 hours
D) Install a raised toilet seat in your bathroom
Correct Answer: D
Rationale
A raised toilet seat is an appropriate intervention for a client following total hip
arthroplasty because it reduces hip flexion, preventing dislocation and making
toileting safer and easier. Option A is incorrect because the incision should be
cleaned with mild soap and water, not hydrogen peroxide, which can damage
healing tissue. Option B is incorrect because crossing the legs, even at the ankles,
can place the hip in an adducted position and increase the risk of dislocation; the
client should maintain the hip in a neutral position. Option C is incorrect because
the incentive spirometer should be used every 1 to 2 hours while awake, not every
8 hours.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
A nurse is planning care for a client following a cardiac catheterization. Which of
the following actions should the nurse take?
A) Keep the client on bed rest for 24 hours
B) Limit the client's fluid intake to 1 L per day
, C) Maintain the client's affected extremity in extension
D) Change the client's dressing every 8 hours
Correct Answer: C
Rationale
The affected extremity should be maintained in extension following cardiac
catheterization to prevent arterial occlusion and facilitate hemostasis at the
insertion site. The client should avoid flexing the hip or knee to prevent bleeding
or hematoma formation. Option A is incorrect because bed rest is typically
maintained for 4 to 6 hours, not 24 hours, depending on the access site and
closure device used. Option B is incorrect because the client should be
encouraged to increase fluid intake to promote excretion of contrast dye and
prevent renal complications. Option D is incorrect because the dressing should be
changed according to facility protocol, typically not every 8 hours unless it
becomes soiled or saturated.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
A nurse is caring for a client who has a lower extremity fracture and a prescription
for crutches. Which of the following client statements indicates that the client is
adapting to their role change?
A) "I will need to have my partner take over shopping for groceries and cooking
the meals for us"
B) "These crutches will make it impossible to care for my child"
C) "I feel bad that I have to ask my partner to keep the house clean"
D) "It's going to be difficult to tell my parents I can't take them to their
appointments anymore"
Correct Answer: A
Rationale
The statement indicating that the client will need to have their partner take over
shopping and cooking demonstrates adaptation to the role change by recognizing
VERSION 2026-2027 EXAM WITH ACTUAL 100 QUESTION AND
CORRECT DETAILED ANSWERS WITH RATIONALES.
A nurse in an emergency department is preparing to perform ocular irrigation for
a client. Which of the following actions should the nurse plan to take?
A) Assess the client's visual acuity prior to irrigation
B) Have the client turn their head toward the unaffected eye
C) Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
D) Perform the irrigation with sterile water for irrigation
Correct Answer: D
Rationale
Sterile water or sterile normal saline is the appropriate irrigation solution for
ocular irrigation. The nurse should use sterile technique to prevent infection and
ensure the safety of the procedure. Option A is incorrect because visual acuity
assessment should be performed after irrigation, not before, to evaluate the
effectiveness of the treatment and the client's eye function. Option B is incorrect
because the client should turn their head toward the affected eye to allow the
irrigating solution to flow from the inner canthus to the outer canthus, preventing
contamination of the unaffected eye. Option C is incorrect because the irrigator
syringe should be held 2.5 to 5 cm (1 to 2 inches) above the eye, not 3.81 cm
specifically, to provide adequate flow without causing trauma.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
A nurse is preparing to administer lactated Ringer's via continuous IV infusion at
200 mL/hr. The IV tubing has a drop factor of 10 drops/mL. How many gtt/min
should the nurse set the IV pump to administer? (Round to the nearest whole
number.)
,Correct Answer: 33 gtt/min
Rationale
To calculate the drip rate in drops per minute, use the formula: (Volume in mL ×
Drop factor) ÷ Time in minutes. The calculation is: (200 mL × 10 drops/mL) ÷ 60
minutes = 2000 ÷ 60 = 33.33 drops/min, which rounds to 33 gtt/min. The nurse
should set the IV pump to deliver 33 drops per minute. This calculation ensures
accurate fluid administration and prevents complications of underhydration or
fluid overload.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
A nurse is providing discharge teaching to a client who has a new prescription for
sublingual nitroglycerin. Which of the following client statements indicates an
understanding of the teaching?
A) "I can keep my medication for 1 year before replacing it"
B) "I should lie down when I take this medication"
C) "I should discontinue this medication if I develop a headache"
D) "I can take up to five tablets in 15 minutes before seeking medical attention"
Correct Answer: B
Rationale
The client should lie down when taking sublingual nitroglycerin to minimize the
risk of orthostatic hypotension and syncope, which are common side effects of the
medication's vasodilatory effects. Option A is incorrect because nitroglycerin
should be replaced every 6 months to maintain potency; the medication is
sensitive to light, heat, and moisture. Option C is incorrect because headache is a
common side effect of nitroglycerin due to vasodilation and does not warrant
discontinuation; the client should be advised that headaches often diminish with
continued use. Option D is incorrect because the client should take up to three
tablets, 5 minutes apart, and seek emergency care if pain persists after three
tablets.
,DIF: Cognitive Level: Evaluate (Evaluation)
TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
A nurse is providing discharge teaching to an older adult client following a left
total hip arthroplasty. Which of the following instructions should the nurse include
in the teaching?
A) Clean the incision daily with hydrogen peroxide
B) You can cross your legs at the ankles when sitting down
C) You should use an incentive spirometer every 8 hours
D) Install a raised toilet seat in your bathroom
Correct Answer: D
Rationale
A raised toilet seat is an appropriate intervention for a client following total hip
arthroplasty because it reduces hip flexion, preventing dislocation and making
toileting safer and easier. Option A is incorrect because the incision should be
cleaned with mild soap and water, not hydrogen peroxide, which can damage
healing tissue. Option B is incorrect because crossing the legs, even at the ankles,
can place the hip in an adducted position and increase the risk of dislocation; the
client should maintain the hip in a neutral position. Option C is incorrect because
the incentive spirometer should be used every 1 to 2 hours while awake, not every
8 hours.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
A nurse is planning care for a client following a cardiac catheterization. Which of
the following actions should the nurse take?
A) Keep the client on bed rest for 24 hours
B) Limit the client's fluid intake to 1 L per day
, C) Maintain the client's affected extremity in extension
D) Change the client's dressing every 8 hours
Correct Answer: C
Rationale
The affected extremity should be maintained in extension following cardiac
catheterization to prevent arterial occlusion and facilitate hemostasis at the
insertion site. The client should avoid flexing the hip or knee to prevent bleeding
or hematoma formation. Option A is incorrect because bed rest is typically
maintained for 4 to 6 hours, not 24 hours, depending on the access site and
closure device used. Option B is incorrect because the client should be
encouraged to increase fluid intake to promote excretion of contrast dye and
prevent renal complications. Option D is incorrect because the dressing should be
changed according to facility protocol, typically not every 8 hours unless it
becomes soiled or saturated.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
A nurse is caring for a client who has a lower extremity fracture and a prescription
for crutches. Which of the following client statements indicates that the client is
adapting to their role change?
A) "I will need to have my partner take over shopping for groceries and cooking
the meals for us"
B) "These crutches will make it impossible to care for my child"
C) "I feel bad that I have to ask my partner to keep the house clean"
D) "It's going to be difficult to tell my parents I can't take them to their
appointments anymore"
Correct Answer: A
Rationale
The statement indicating that the client will need to have their partner take over
shopping and cooking demonstrates adaptation to the role change by recognizing
