ATI RN 2 EXAM – QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS |
PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains: - Pharmacological and Parenteral Therapies - Management of Care and
Leadership - Reduction of Risk Potential - Physiological Adaptation - Safety and Infection
Control - Psychosocial Integrity - Health Promotion and Maintenance - Nutrition and Oral
Hydration
Introduction: The purpose of this comprehensive assessment is to evaluate the clinical
competence, critical thinking, and decision-making capabilities of graduate nurses preparing
for professional licensure. This examination assesses foundational theory, applied
professional knowledge, regulatory compliance, and ethical nursing practice. Utilizing a
combination of multiple-choice questions and complex, scenario-based clinical situations, the
assessment places a heavy emphasis on real-world application. Candidates must
demonstrate the ability to prioritize care, manage risk, and adapt interventions to meet
changing client needs under varying levels of physiological and psychosocial stress, ensuring
safe and effective nursing care across diverse healthcare settings.
Section One: Questions 1–100
Question 1 A nurse is caring for a client who is 24 hours postoperative following an
abdominal hysterectomy. Which of the following findings should the nurse report to the
provider immediately?
A. Urinary output of 25 mL/hr over the past 2 hours B. Serosanguineous drainage on the
abdominal dressing C. Decreased bowel sounds in all four quadrants D. Incisional pain rated
as 6 on a scale of 0 to 10
A. Option Explanation: Urinary output less than 30 mL/hr can indicate hypovolemia,
decreased renal perfusion, or urinary tract injury during surgery, requiring immediate
medical evaluation.
Question 2 A nurse is reviewing the laboratory results of a client who is receiving a
continuous intravenous heparin infusion for a deep-vein thrombosis. The client's activated
partial thromboplastin time (aPTT) is 95 seconds. Which of the following actions should the
nurse take?
A. Increase the heparin infusion rate by 100 units/hr B. Continue the infusion at the current
prescribed rate C. Stop the heparin infusion and prepare protamine sulfate D. Decrease the
infusion rate and recheck the aPTT in 1 hour
C. Option Explanation: An aPTT of 95 seconds is significantly above the therapeutic
range (typically 1.5 to 2.5 times the control value, or 60 to 80 seconds), placing the client at
high risk for bleeding. The infusion must be stopped.
,Question 3 A charge nurse is observing a newly licensed nurse perform tracheostomy care
for a client. Which of the following actions by the newly licensed nurse requires
intervention?
A. Cleaning the outer cannula surface with normal saline B. Securing new tracheostomy ties
before removing the old ones C. Using a sterile applicator to apply split-gauze under the
faceplate D. Cutting a sterile gauze pad to place under the tracheostomy tube faceplate
D. Option Explanation: Cutting gauze pads creates loose fibers that can be aspirated
into the trachea, causing inflammation or infection. Prefabricated split-gauze pads must be
used instead.
Question 4 A nurse is preparing to administer digoxin 0.25 mg orally to a client who has
heart failure. Which of the following findings should cause the nurse to hold the medication?
A. Blood pressure 142/88 mm Hg B. Apical pulse 52 beats per minute C. Respiratory rate 16
breaths per minute D. Serum potassium level 4.2 mEq/L
B. Option Explanation: Digoxin decreases the heart rate. The medication should be
held, and the provider notified, if the apical pulse is less than 60 beats per minute in an
adult client.
Question 5 A nurse is planning care for an older adult client who is at risk for pressure injury
development. Which of the following interventions should the nurse include in the plan?
A. Massage reddened bony prominences daily B. Reposition the client every 4 hours while in
bed C. Keep the head of the bed elevated at 45 degrees D. Apply a lipid-rich moisturizing
lotion to dry skin areas
D. Option Explanation: Hydrating dry skin helps maintain epidermal integrity.
Massaging reddened areas causes deep tissue damage, repositioning should occur at least
every 2 hours, and the head of the bed should be at 30 degrees or less to minimize shearing.
Question 6 A nurse in an emergency department is assessing a client who has a suspected
legal or forensic medical status following an assault. Which of the following actions should
the nurse prioritize to preserve evidence?
A. Place the client's clothing in a sealed plastic bag B. Photograph the injuries before
obtaining written consent C. Document the client's statements using objective, structural
descriptions D. Have the client wash their hands before obtaining swabs
C. Option Explanation: Nursing documentation must use objective, verbatim quotes
from the client to preserve the integrity of statements. Clothing should go in paper bags to
prevent moisture retention and mold, and consent is required for photographs.
Question 7 A nurse is preparing to administer blood to a client who has severe anemia.
Which of the following actions should the nurse take first?
,A. Verify the client's identity with another nurse using two identifiers B. Obtain the client's
vital signs to establish baseline data C. Ensure a large-bore intravenous catheter is patent D.
Prime the blood administration tubing with 0.9% sodium chloride
B. Option Explanation: Obtaining baseline vital signs is the priority assessment action
before initiating a blood transfusion to ensure any subsequent adverse reactions can be
accurately identified by comparison.
Question 8 A nurse is caring for a client who has a prescription for a clear liquid diet. Which
of the following food items should the nurse offer to the client?
A. Vanilla ice cream B. Fat-free broth C. Orange juice with pulp D. Oatmeal gruel
B. Option Explanation: Clear liquids consist of foods that are liquid at room
temperature and transparent. Fat-free broth, apple juice, gelatin, and tea are acceptable
options, whereas ice cream and pulp are not.
Question 9 A nurse is assessing a client who is receiving magnesium sulfate via continuous
intravenous infusion for preeclampsia. Which of the following findings indicates magnesium
sulfate toxicity?
A. Hyperreflexia of the deep tendons B. Urinary output of 45 mL/hr C. Respiratory rate of 10
breaths per minute D. Blood pressure of 150/95 mm Hg
C. Option Explanation: Magnesium sulfate is a central nervous system depressant.
Toxicity is manifested by respiratory depression (less than 12 breaths/min), loss of deep
tendon reflexes, and oliguria.
Question 10 A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus
about foot care. Which of the following instructions should the nurse include?
A. Soak the feet in warm water for 20 minutes daily B. Apply lotion between the toes after
washing C. Cut toenails in a rounded shape close to the nail bed D. Wear clean, dry cotton
socks every day
D. Option Explanation: Cotton socks absorb moisture and protect the feet from
friction and injury. Soaking feet increases maceration risk, lotion between toes promotes
fungal growth, and nails should be cut straight across.
Question 11 A nurse is prioritizing care for four clients at the start of a shift. Which of the
following clients should the nurse assess first?
A. A client who has asthma and requested an albuterol inhaler 15 minutes ago B. A client
who has diabetes mellitus and a fasting blood glucose of 145 mg/dL C. A client post-
appendectomy with a temperature of 37.8 C (100 F) D. A client with chronic obstructive
pulmonary disease (COPD) and an O2 saturation of 90%
, A. Option Explanation: Airway and breathing take precedence. A client with asthma
requiring a rescue bronchodilator indicates acute respiratory distress or an impending
attack, requiring immediate assessment.
Question 12 A nurse is caring for an infant who is scheduled for a surgical repair of a cleft lip.
Which of the following interventions should the nurse implement postoperatively?
A. Place the infant in a prone position to drain secretions B. Use a standard nipple to feed
the infant immediately C. Apply bilateral elbow restraints to the infant D. Clean the suture
line with full-strength hydrogen peroxide
C. Option Explanation: Postoperatively, elbow restraints are used to prevent the
infant from touching or scratching the suture line, preserving the surgical repair. The infant
should not be placed prone as it can cause trauma to the face.
Question 13 A nurse is evaluating an assistive personnel (AP) who is transferring a client
from a bed to a chair. Which of the following actions by the AP indicates proper body
mechanics?
A. Bending at the waist when lifting the client B. Keeping the feet close together during the
pivot C. Holding the client at arm's length during the transfer D. Flexing the knees and hips
before lifting
D. Option Explanation: Flexing the knees and hips lowers the center of gravity and
uses the strong muscles of the thighs and buttocks rather than the back, preventing injury.
Question 14 A nurse is reviewing the medication administration record of a client who has a
new prescription for lithium carbonate. Which of the following current medications should
the nurse identify as increasing the risk for lithium toxicity?
A. Furosemide B. Acetaminophen C. Levothyroxine D. Atorvastatin
A. Option Explanation: Diuretics like furosemide promote sodium excretion. Sodium
depletion causes the kidneys to retain lithium, leading to toxic accumulations of lithium in
the bloodstream.
Question 15 A nurse is conducting a home health visit for an older adult client who lives
alone. Which of the following observations indicates a safety hazard in the home
environment?
A. Extension cords run flat against the walls under furniture B. A clear pathway through the
living room to the doorway C. Loose throw rugs placed over hardwood floors in the hallway
D. Grab bars installed next to the toilet and inside the shower
C. Option Explanation: Loose throw rugs are a major tripping and slipping hazard for
older adult clients, increasing the risk of falls and subsequent fractures.
PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains: - Pharmacological and Parenteral Therapies - Management of Care and
Leadership - Reduction of Risk Potential - Physiological Adaptation - Safety and Infection
Control - Psychosocial Integrity - Health Promotion and Maintenance - Nutrition and Oral
Hydration
Introduction: The purpose of this comprehensive assessment is to evaluate the clinical
competence, critical thinking, and decision-making capabilities of graduate nurses preparing
for professional licensure. This examination assesses foundational theory, applied
professional knowledge, regulatory compliance, and ethical nursing practice. Utilizing a
combination of multiple-choice questions and complex, scenario-based clinical situations, the
assessment places a heavy emphasis on real-world application. Candidates must
demonstrate the ability to prioritize care, manage risk, and adapt interventions to meet
changing client needs under varying levels of physiological and psychosocial stress, ensuring
safe and effective nursing care across diverse healthcare settings.
Section One: Questions 1–100
Question 1 A nurse is caring for a client who is 24 hours postoperative following an
abdominal hysterectomy. Which of the following findings should the nurse report to the
provider immediately?
A. Urinary output of 25 mL/hr over the past 2 hours B. Serosanguineous drainage on the
abdominal dressing C. Decreased bowel sounds in all four quadrants D. Incisional pain rated
as 6 on a scale of 0 to 10
A. Option Explanation: Urinary output less than 30 mL/hr can indicate hypovolemia,
decreased renal perfusion, or urinary tract injury during surgery, requiring immediate
medical evaluation.
Question 2 A nurse is reviewing the laboratory results of a client who is receiving a
continuous intravenous heparin infusion for a deep-vein thrombosis. The client's activated
partial thromboplastin time (aPTT) is 95 seconds. Which of the following actions should the
nurse take?
A. Increase the heparin infusion rate by 100 units/hr B. Continue the infusion at the current
prescribed rate C. Stop the heparin infusion and prepare protamine sulfate D. Decrease the
infusion rate and recheck the aPTT in 1 hour
C. Option Explanation: An aPTT of 95 seconds is significantly above the therapeutic
range (typically 1.5 to 2.5 times the control value, or 60 to 80 seconds), placing the client at
high risk for bleeding. The infusion must be stopped.
,Question 3 A charge nurse is observing a newly licensed nurse perform tracheostomy care
for a client. Which of the following actions by the newly licensed nurse requires
intervention?
A. Cleaning the outer cannula surface with normal saline B. Securing new tracheostomy ties
before removing the old ones C. Using a sterile applicator to apply split-gauze under the
faceplate D. Cutting a sterile gauze pad to place under the tracheostomy tube faceplate
D. Option Explanation: Cutting gauze pads creates loose fibers that can be aspirated
into the trachea, causing inflammation or infection. Prefabricated split-gauze pads must be
used instead.
Question 4 A nurse is preparing to administer digoxin 0.25 mg orally to a client who has
heart failure. Which of the following findings should cause the nurse to hold the medication?
A. Blood pressure 142/88 mm Hg B. Apical pulse 52 beats per minute C. Respiratory rate 16
breaths per minute D. Serum potassium level 4.2 mEq/L
B. Option Explanation: Digoxin decreases the heart rate. The medication should be
held, and the provider notified, if the apical pulse is less than 60 beats per minute in an
adult client.
Question 5 A nurse is planning care for an older adult client who is at risk for pressure injury
development. Which of the following interventions should the nurse include in the plan?
A. Massage reddened bony prominences daily B. Reposition the client every 4 hours while in
bed C. Keep the head of the bed elevated at 45 degrees D. Apply a lipid-rich moisturizing
lotion to dry skin areas
D. Option Explanation: Hydrating dry skin helps maintain epidermal integrity.
Massaging reddened areas causes deep tissue damage, repositioning should occur at least
every 2 hours, and the head of the bed should be at 30 degrees or less to minimize shearing.
Question 6 A nurse in an emergency department is assessing a client who has a suspected
legal or forensic medical status following an assault. Which of the following actions should
the nurse prioritize to preserve evidence?
A. Place the client's clothing in a sealed plastic bag B. Photograph the injuries before
obtaining written consent C. Document the client's statements using objective, structural
descriptions D. Have the client wash their hands before obtaining swabs
C. Option Explanation: Nursing documentation must use objective, verbatim quotes
from the client to preserve the integrity of statements. Clothing should go in paper bags to
prevent moisture retention and mold, and consent is required for photographs.
Question 7 A nurse is preparing to administer blood to a client who has severe anemia.
Which of the following actions should the nurse take first?
,A. Verify the client's identity with another nurse using two identifiers B. Obtain the client's
vital signs to establish baseline data C. Ensure a large-bore intravenous catheter is patent D.
Prime the blood administration tubing with 0.9% sodium chloride
B. Option Explanation: Obtaining baseline vital signs is the priority assessment action
before initiating a blood transfusion to ensure any subsequent adverse reactions can be
accurately identified by comparison.
Question 8 A nurse is caring for a client who has a prescription for a clear liquid diet. Which
of the following food items should the nurse offer to the client?
A. Vanilla ice cream B. Fat-free broth C. Orange juice with pulp D. Oatmeal gruel
B. Option Explanation: Clear liquids consist of foods that are liquid at room
temperature and transparent. Fat-free broth, apple juice, gelatin, and tea are acceptable
options, whereas ice cream and pulp are not.
Question 9 A nurse is assessing a client who is receiving magnesium sulfate via continuous
intravenous infusion for preeclampsia. Which of the following findings indicates magnesium
sulfate toxicity?
A. Hyperreflexia of the deep tendons B. Urinary output of 45 mL/hr C. Respiratory rate of 10
breaths per minute D. Blood pressure of 150/95 mm Hg
C. Option Explanation: Magnesium sulfate is a central nervous system depressant.
Toxicity is manifested by respiratory depression (less than 12 breaths/min), loss of deep
tendon reflexes, and oliguria.
Question 10 A nurse is teaching a client who has a new diagnosis of Type 1 diabetes mellitus
about foot care. Which of the following instructions should the nurse include?
A. Soak the feet in warm water for 20 minutes daily B. Apply lotion between the toes after
washing C. Cut toenails in a rounded shape close to the nail bed D. Wear clean, dry cotton
socks every day
D. Option Explanation: Cotton socks absorb moisture and protect the feet from
friction and injury. Soaking feet increases maceration risk, lotion between toes promotes
fungal growth, and nails should be cut straight across.
Question 11 A nurse is prioritizing care for four clients at the start of a shift. Which of the
following clients should the nurse assess first?
A. A client who has asthma and requested an albuterol inhaler 15 minutes ago B. A client
who has diabetes mellitus and a fasting blood glucose of 145 mg/dL C. A client post-
appendectomy with a temperature of 37.8 C (100 F) D. A client with chronic obstructive
pulmonary disease (COPD) and an O2 saturation of 90%
, A. Option Explanation: Airway and breathing take precedence. A client with asthma
requiring a rescue bronchodilator indicates acute respiratory distress or an impending
attack, requiring immediate assessment.
Question 12 A nurse is caring for an infant who is scheduled for a surgical repair of a cleft lip.
Which of the following interventions should the nurse implement postoperatively?
A. Place the infant in a prone position to drain secretions B. Use a standard nipple to feed
the infant immediately C. Apply bilateral elbow restraints to the infant D. Clean the suture
line with full-strength hydrogen peroxide
C. Option Explanation: Postoperatively, elbow restraints are used to prevent the
infant from touching or scratching the suture line, preserving the surgical repair. The infant
should not be placed prone as it can cause trauma to the face.
Question 13 A nurse is evaluating an assistive personnel (AP) who is transferring a client
from a bed to a chair. Which of the following actions by the AP indicates proper body
mechanics?
A. Bending at the waist when lifting the client B. Keeping the feet close together during the
pivot C. Holding the client at arm's length during the transfer D. Flexing the knees and hips
before lifting
D. Option Explanation: Flexing the knees and hips lowers the center of gravity and
uses the strong muscles of the thighs and buttocks rather than the back, preventing injury.
Question 14 A nurse is reviewing the medication administration record of a client who has a
new prescription for lithium carbonate. Which of the following current medications should
the nurse identify as increasing the risk for lithium toxicity?
A. Furosemide B. Acetaminophen C. Levothyroxine D. Atorvastatin
A. Option Explanation: Diuretics like furosemide promote sodium excretion. Sodium
depletion causes the kidneys to retain lithium, leading to toxic accumulations of lithium in
the bloodstream.
Question 15 A nurse is conducting a home health visit for an older adult client who lives
alone. Which of the following observations indicates a safety hazard in the home
environment?
A. Extension cords run flat against the walls under furniture B. A clear pathway through the
living room to the doorway C. Loose throw rugs placed over hardwood floors in the hallway
D. Grab bars installed next to the toilet and inside the shower
C. Option Explanation: Loose throw rugs are a major tripping and slipping hazard for
older adult clients, increasing the risk of falls and subsequent fractures.
