ATI PN Adult Medical Surgical (Med-Surg)
Proctored Exam with NGN 120 Questions
and Answers
### Question 1
A nurse is assessing a client with heart failure who reports sudden
onset of dyspnea and is coughing up pink, frothy sputum. Which
action should the nurse take first?
**A) Place the client in high-Fowler's position**
B) Administer furosemide IV push
C) Apply oxygen via non-rebreather mask
D) Notify the healthcare provider immediately
**Answer: A**
**Rationale:** The client is experiencing acute pulmonary edema.
The priority intervention is to position the client upright (high-
Fowler's) to reduce venous return (preload) and facilitate breathing.
Oxygen and furosemide are then given, but positioning is the
immediate first step .
---
### Question 2
,A nurse is assessing a client with heart failure. Which assessment
finding requires immediate intervention?
A) Jugular vein distention
B) 2+ pitting edema in lower extremities
**C) Oxygen saturation 89% on room air**
D) Weight gain of 1 kg (2.2 lb) over 2 days
**Answer: C**
**Rationale:** Oxygen saturation of 89% indicates hypoxemia and is
a priority finding. Low SpO₂ signals worsening gas exchange and may
precede respiratory failure. JVD, edema, and gradual weight gain are
expected findings in HF but do not require urgent action unless
severe .
---
### Question 3
A nurse is assessing a client with heart failure. Which finding is an
early indication of fluid volume overload?
A) Jugular vein distention
**B) Weight gain of 2 lbs (1 kg) in 24 hours**
C) Crackles in the lung bases
,D) Peripheral edema (2+)
**Answer: B**
**Rationale:** Weight gain is an early indicator of fluid retention
because 1 kg (2.2 lbs) of weight gain equals approximately 1 liter of
fluid. Jugular vein distention, crackles, and peripheral edema are later
signs of fluid overload .
---
### Question 4
A client with angina pectoris is prescribed nitroglycerin sublingual.
The nurse should instruct the client to:
A) Swallow the tablet with water
**B) Take one tablet every 5 minutes for up to three doses for chest
pain**
C) Store the tablets in the refrigerator
D) Take the medication with food to prevent nausea
**Answer: B**
**Rationale:** Standard instruction for nitroglycerin sublingual: take
one tablet at the onset of chest pain, then every 5 minutes for up to
, three doses. If pain is not relieved after the first tablet, call 911
immediately .
---
### Question 5
A client with hypertension is prescribed hydrochlorothiazide. The
nurse should monitor for which electrolyte imbalance?
A) Hyperkalemia
**B) Hypokalemia**
C) Hypernatremia
D) Hypocalcemia
**Answer: B**
**Rationale:** Hydrochlorothiazide is a thiazide diuretic that causes
potassium wasting, leading to hypokalemia (low potassium). Signs
include muscle weakness, fatigue, and cardiac arrhythmias .
---
### Question 6
Proctored Exam with NGN 120 Questions
and Answers
### Question 1
A nurse is assessing a client with heart failure who reports sudden
onset of dyspnea and is coughing up pink, frothy sputum. Which
action should the nurse take first?
**A) Place the client in high-Fowler's position**
B) Administer furosemide IV push
C) Apply oxygen via non-rebreather mask
D) Notify the healthcare provider immediately
**Answer: A**
**Rationale:** The client is experiencing acute pulmonary edema.
The priority intervention is to position the client upright (high-
Fowler's) to reduce venous return (preload) and facilitate breathing.
Oxygen and furosemide are then given, but positioning is the
immediate first step .
---
### Question 2
,A nurse is assessing a client with heart failure. Which assessment
finding requires immediate intervention?
A) Jugular vein distention
B) 2+ pitting edema in lower extremities
**C) Oxygen saturation 89% on room air**
D) Weight gain of 1 kg (2.2 lb) over 2 days
**Answer: C**
**Rationale:** Oxygen saturation of 89% indicates hypoxemia and is
a priority finding. Low SpO₂ signals worsening gas exchange and may
precede respiratory failure. JVD, edema, and gradual weight gain are
expected findings in HF but do not require urgent action unless
severe .
---
### Question 3
A nurse is assessing a client with heart failure. Which finding is an
early indication of fluid volume overload?
A) Jugular vein distention
**B) Weight gain of 2 lbs (1 kg) in 24 hours**
C) Crackles in the lung bases
,D) Peripheral edema (2+)
**Answer: B**
**Rationale:** Weight gain is an early indicator of fluid retention
because 1 kg (2.2 lbs) of weight gain equals approximately 1 liter of
fluid. Jugular vein distention, crackles, and peripheral edema are later
signs of fluid overload .
---
### Question 4
A client with angina pectoris is prescribed nitroglycerin sublingual.
The nurse should instruct the client to:
A) Swallow the tablet with water
**B) Take one tablet every 5 minutes for up to three doses for chest
pain**
C) Store the tablets in the refrigerator
D) Take the medication with food to prevent nausea
**Answer: B**
**Rationale:** Standard instruction for nitroglycerin sublingual: take
one tablet at the onset of chest pain, then every 5 minutes for up to
, three doses. If pain is not relieved after the first tablet, call 911
immediately .
---
### Question 5
A client with hypertension is prescribed hydrochlorothiazide. The
nurse should monitor for which electrolyte imbalance?
A) Hyperkalemia
**B) Hypokalemia**
C) Hypernatremia
D) Hypocalcemia
**Answer: B**
**Rationale:** Hydrochlorothiazide is a thiazide diuretic that causes
potassium wasting, leading to hypokalemia (low potassium). Signs
include muscle weakness, fatigue, and cardiac arrhythmias .
---
### Question 6
