ATI Clinical Judgment Assessment
Comprehensive Examination — 150 Multiple-Choice Questions
EXAM TITLE: ATI Clinical Judgment Assessment: Advanced Clinical Reasoning, Priority-Setting, and Next Generation
NCLEX Clinical Judgment Measurement Model Integration for High-Stakes Nursing Licensure Readiness
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing an initial assessment on a 72-year-old client admitted with shortness of breath. Which finding should the nurse recognize as the
most significant cue requiring immediate further investigation?
A) Client reports occasional coughing with clear sputum
B) Client has a history of hypertension controlled with medication
C) Client demonstrates jugular venous distention while sitting at 45 degrees
D) Client's skin is warm and dry to touch
Correct Answer: C
Rationale: Jugular venous distention (JVD) is a significant clinical cue indicating increased central venous pressure, commonly associated with right-sided
heart failure, pulmonary hypertension, or pericardial effusion. This finding warrants immediate further investigation as it suggests hemodynamic
compromise. Clear sputum with occasional coughing, controlled hypertension, and warm dry skin are less concerning findings that do not indicate acute
deterioration.
Question 2
A nurse is reviewing a client's electronic health record. Which piece of information represents a subjective cue that the nurse should document?
A) Blood pressure 142/88 mmHg
B) Serum potassium 3.4 mEq/L
C) Client states, "I feel like my heart is racing"
D) Oxygen saturation 94% on room air
Correct Answer: C
Rationale: Subjective data are information reported by the client and cannot be independently verified by the nurse. The client's statement about feeling
heart racing is subjective. Blood pressure, serum potassium, and oxygen saturation are objective data that can be measured and verified.
Question 3
A nurse is assessing a client who reports abdominal pain. Which assessment technique should the nurse use to recognize cues related to peritoneal
irritation?
A) Auscultation of bowel sounds in all four quadrants
B) Palpation for rebound tenderness and guarding
C) Percussion for tympany over the gastric bubble
D) Inspection for abdominal distention and skin changes
Correct Answer: B
Rationale: Rebound tenderness and guarding are classic cues of peritoneal irritation, which may indicate appendicitis, peritonitis, or other intra-abdominal
,pathology. While all assessment techniques provide valuable information, palpation for rebound tenderness directly assesses for peritoneal signs.
Auscultation, percussion, and inspection provide supportive but less specific data.
Question 4
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse recognize as an
early cue of respiratory decline?
A) Increased anteroposterior chest diameter
B) Use of accessory muscles during inspiration
C) Pursed-lip breathing during exhalation
D) Barrel-shaped chest appearance
Correct Answer: B
Rationale: Use of accessory muscles (sternocleidomastoid, trapezius, intercostal muscles) during inspiration is an early cue of increased work of breathing
and impending respiratory compromise. Barrel-shaped chest and pursed-lip breathing are chronic adaptations in COPD patients. Increased AP diameter is
a structural change that develops over time.
Question 5
A nurse is assessing a client who underwent abdominal surgery 24 hours ago. Which cue should the nurse recognize as an early sign of a potential wound
infection?
A) Serosanguineous drainage on the dressing
B) Temperature of 37.8°C (100.0°F)
C) Erythema extending 2 cm from the incision site
D) Client reports pain at the incision site rated 4/10
Correct Answer: C
Rationale: Erythema (redness) extending beyond the immediate wound edges is an early cue of inflammation and potential infection. While fever may
indicate infection, low-grade fever can be a normal postoperative response. Serosanguineous drainage is expected in the first 24-48 hours. Pain is expected
postoperatively.
Question 6
A nurse is performing a neurological assessment on a client following a stroke. Which finding should the nurse recognize as the most concerning cue?
A) Client has mild dysarthria when speaking
B) Client's Glasgow Coma Scale score decreases from 15 to 13
C) Client reports a headache rated 4/10
D) Client has slight weakness in the right upper extremity
Correct Answer: B
Rationale: A decrease in Glasgow Coma Scale score from 15 to 13 represents a significant decline in neurological status, indicating potential increased
intracranial pressure or extension of the stroke. This requires immediate intervention. Mild dysarthria, slight weakness, and mild headache are concerning
but do not indicate the same level of acute deterioration.
Question 7
A nurse is reviewing laboratory results for a client with chronic kidney disease. Which laboratory value should the nurse recognize as a critical cue requiring
immediate notification of the healthcare provider?
A) Serum creatinine 2.8 mg/dL (baseline 2.5 mg/dL)
B) Serum potassium 6.8 mEq/L
,C) Blood urea nitrogen 45 mg/dL
D) Hemoglobin 10.2 g/dL
Correct Answer: B
Rationale: A serum potassium of 6.8 mEq/L represents severe hyperkalemia, which can cause life-threatening cardiac dysrhythmias. This is a critical value
requiring immediate intervention. While elevated creatinine and BUN are expected in chronic kidney disease, they do not pose the same immediate threat.
Mild anemia is common in CKD and does not require emergent intervention.
Question 8
A nurse is assessing a client receiving a blood transfusion. Which cue should the nurse recognize as an early sign of a transfusion reaction?
A) Client reports a mild headache
B) Client's temperature increases from 37.0°C to 37.8°C (98.6°F to 100.0°F)
C) Client develops low back pain and chills
D) Client's heart rate increases from 76 to 82 beats per minute
Correct Answer: C
Rationale: Low back pain and chills are classic early cues of an acute hemolytic transfusion reaction. These symptoms occur when antibodies in the
recipient's blood attack the donor's red blood cells. Mild temperature elevation and slight tachycardia can occur with transfusion but are less specific. Mild
headache is not a primary indicator of transfusion reaction.
Question 9
A nurse is assessing a client with diabetic ketoacidosis (DKA). Which respiratory pattern should the nurse recognize as a cue of metabolic acidosis?
A) Cheyne-Stokes respirations
B) Biot's respirations
C) Kussmaul respirations
D) Apneustic respirations
Correct Answer: C
Rationale: Kussmaul respirations (deep, rapid, sighing breaths) are a compensatory mechanism for metabolic acidosis, as seen in DKA. The body attempts
to blow off excess carbon dioxide to compensate for metabolic acidosis. Cheyne-Stokes is associated with brain injury, Biot's with increased intracranial
pressure, and apneustic with brainstem damage.
Question 10
A nurse is assessing a client's pain. Which component of the pain assessment provides the most reliable cue for determining the effectiveness of
interventions?
A) The client's behavior and facial expression
B) The client's self-report of pain using a numerical rating scale
C) The client's vital signs changes
D) The nurse's observation of the client's activity level
Correct Answer: B
Rationale: Pain is a subjective experience, and the client's self-report is the most reliable indicator of pain intensity. Behavioral observations and vital signs
can be influenced by many factors and may not accurately reflect pain. The numerical rating scale provides a consistent, quantifiable measure to evaluate
intervention effectiveness.
Question 11
A nurse is caring for a client with a central venous catheter. Which cue should alert the nurse to a possible catheter-related bloodstream infection?
, A) The catheter insertion site is clean and dry
B) The client's white blood cell count is 8,500/mm³
C) The client develops chills and fever 30 minutes after catheter flushing
D) The client reports mild discomfort at the catheter site
Correct Answer: C
Rationale: Chills and fever following catheter flushing suggest the presence of a biofilm or infection within the catheter lumen that is being dislodged into
the bloodstream. This is a classic presentation of catheter-related bloodstream infection. A clean insertion site and normal WBC are reassuring. Mild
discomfort may be expected.
Question 12
A nurse is assessing a client with suspected pulmonary embolism. Which assessment finding should the nurse recognize as the most significant cue?
A) Client reports sudden onset of pleuritic chest pain
B) Client's respiratory rate is 22 breaths per minute
C) Client's heart rate is 98 beats per minute
D) Client has mild anxiety
Correct Answer: A
Rationale: Sudden onset of pleuritic chest pain is a classic cue of pulmonary embolism, along with dyspnea, tachypnea, and hemoptysis. While tachycardia
and tachypnea are also signs, the sudden nature and quality of the chest pain are particularly significant. Anxiety may accompany but is less specific.
Question 13
A nurse is assessing a client with heart failure. Which cue indicates that the client's condition is worsening?
A) Client reports a 0.5 kg (1 lb) weight gain over 1 week
B) Client has 1+ pedal edema bilaterally
C) Client develops paroxysmal nocturnal dyspnea
D) Client's jugular veins are visible when lying flat
Correct Answer: C
Rationale: Paroxysmal nocturnal dyspnea (PND) is a significant cue of worsening heart failure, indicating fluid accumulation in the lungs during
recumbency. This represents a more advanced stage of heart failure than peripheral edema or mild weight gain. JVD when lying flat can be normal but
should be evaluated at 45 degrees.
Question 14
A nurse is reviewing a client's medication administration record. Which cue should alert the nurse to a potential medication error?
A) A medication is ordered for a different time than the client usually receives it
B) A medication is ordered that the client has taken previously without issues
C) The client's allergy list includes an allergy to the prescribed antibiotic
D) The medication is available in both tablet and liquid forms
Correct Answer: C
Rationale: A documented allergy to a prescribed medication is a critical safety cue that requires immediate action. Administering a medication to which a
client has a known allergy could result in a severe allergic reaction. Time changes, previous tolerance, and different formulations do not present the same
safety concern.
Question 15
A nurse is assessing a client who is 2 days postoperative. Which finding should the nurse recognize as a cue of potential venous thromboembolism?
Comprehensive Examination — 150 Multiple-Choice Questions
EXAM TITLE: ATI Clinical Judgment Assessment: Advanced Clinical Reasoning, Priority-Setting, and Next Generation
NCLEX Clinical Judgment Measurement Model Integration for High-Stakes Nursing Licensure Readiness
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing an initial assessment on a 72-year-old client admitted with shortness of breath. Which finding should the nurse recognize as the
most significant cue requiring immediate further investigation?
A) Client reports occasional coughing with clear sputum
B) Client has a history of hypertension controlled with medication
C) Client demonstrates jugular venous distention while sitting at 45 degrees
D) Client's skin is warm and dry to touch
Correct Answer: C
Rationale: Jugular venous distention (JVD) is a significant clinical cue indicating increased central venous pressure, commonly associated with right-sided
heart failure, pulmonary hypertension, or pericardial effusion. This finding warrants immediate further investigation as it suggests hemodynamic
compromise. Clear sputum with occasional coughing, controlled hypertension, and warm dry skin are less concerning findings that do not indicate acute
deterioration.
Question 2
A nurse is reviewing a client's electronic health record. Which piece of information represents a subjective cue that the nurse should document?
A) Blood pressure 142/88 mmHg
B) Serum potassium 3.4 mEq/L
C) Client states, "I feel like my heart is racing"
D) Oxygen saturation 94% on room air
Correct Answer: C
Rationale: Subjective data are information reported by the client and cannot be independently verified by the nurse. The client's statement about feeling
heart racing is subjective. Blood pressure, serum potassium, and oxygen saturation are objective data that can be measured and verified.
Question 3
A nurse is assessing a client who reports abdominal pain. Which assessment technique should the nurse use to recognize cues related to peritoneal
irritation?
A) Auscultation of bowel sounds in all four quadrants
B) Palpation for rebound tenderness and guarding
C) Percussion for tympany over the gastric bubble
D) Inspection for abdominal distention and skin changes
Correct Answer: B
Rationale: Rebound tenderness and guarding are classic cues of peritoneal irritation, which may indicate appendicitis, peritonitis, or other intra-abdominal
,pathology. While all assessment techniques provide valuable information, palpation for rebound tenderness directly assesses for peritoneal signs.
Auscultation, percussion, and inspection provide supportive but less specific data.
Question 4
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse recognize as an
early cue of respiratory decline?
A) Increased anteroposterior chest diameter
B) Use of accessory muscles during inspiration
C) Pursed-lip breathing during exhalation
D) Barrel-shaped chest appearance
Correct Answer: B
Rationale: Use of accessory muscles (sternocleidomastoid, trapezius, intercostal muscles) during inspiration is an early cue of increased work of breathing
and impending respiratory compromise. Barrel-shaped chest and pursed-lip breathing are chronic adaptations in COPD patients. Increased AP diameter is
a structural change that develops over time.
Question 5
A nurse is assessing a client who underwent abdominal surgery 24 hours ago. Which cue should the nurse recognize as an early sign of a potential wound
infection?
A) Serosanguineous drainage on the dressing
B) Temperature of 37.8°C (100.0°F)
C) Erythema extending 2 cm from the incision site
D) Client reports pain at the incision site rated 4/10
Correct Answer: C
Rationale: Erythema (redness) extending beyond the immediate wound edges is an early cue of inflammation and potential infection. While fever may
indicate infection, low-grade fever can be a normal postoperative response. Serosanguineous drainage is expected in the first 24-48 hours. Pain is expected
postoperatively.
Question 6
A nurse is performing a neurological assessment on a client following a stroke. Which finding should the nurse recognize as the most concerning cue?
A) Client has mild dysarthria when speaking
B) Client's Glasgow Coma Scale score decreases from 15 to 13
C) Client reports a headache rated 4/10
D) Client has slight weakness in the right upper extremity
Correct Answer: B
Rationale: A decrease in Glasgow Coma Scale score from 15 to 13 represents a significant decline in neurological status, indicating potential increased
intracranial pressure or extension of the stroke. This requires immediate intervention. Mild dysarthria, slight weakness, and mild headache are concerning
but do not indicate the same level of acute deterioration.
Question 7
A nurse is reviewing laboratory results for a client with chronic kidney disease. Which laboratory value should the nurse recognize as a critical cue requiring
immediate notification of the healthcare provider?
A) Serum creatinine 2.8 mg/dL (baseline 2.5 mg/dL)
B) Serum potassium 6.8 mEq/L
,C) Blood urea nitrogen 45 mg/dL
D) Hemoglobin 10.2 g/dL
Correct Answer: B
Rationale: A serum potassium of 6.8 mEq/L represents severe hyperkalemia, which can cause life-threatening cardiac dysrhythmias. This is a critical value
requiring immediate intervention. While elevated creatinine and BUN are expected in chronic kidney disease, they do not pose the same immediate threat.
Mild anemia is common in CKD and does not require emergent intervention.
Question 8
A nurse is assessing a client receiving a blood transfusion. Which cue should the nurse recognize as an early sign of a transfusion reaction?
A) Client reports a mild headache
B) Client's temperature increases from 37.0°C to 37.8°C (98.6°F to 100.0°F)
C) Client develops low back pain and chills
D) Client's heart rate increases from 76 to 82 beats per minute
Correct Answer: C
Rationale: Low back pain and chills are classic early cues of an acute hemolytic transfusion reaction. These symptoms occur when antibodies in the
recipient's blood attack the donor's red blood cells. Mild temperature elevation and slight tachycardia can occur with transfusion but are less specific. Mild
headache is not a primary indicator of transfusion reaction.
Question 9
A nurse is assessing a client with diabetic ketoacidosis (DKA). Which respiratory pattern should the nurse recognize as a cue of metabolic acidosis?
A) Cheyne-Stokes respirations
B) Biot's respirations
C) Kussmaul respirations
D) Apneustic respirations
Correct Answer: C
Rationale: Kussmaul respirations (deep, rapid, sighing breaths) are a compensatory mechanism for metabolic acidosis, as seen in DKA. The body attempts
to blow off excess carbon dioxide to compensate for metabolic acidosis. Cheyne-Stokes is associated with brain injury, Biot's with increased intracranial
pressure, and apneustic with brainstem damage.
Question 10
A nurse is assessing a client's pain. Which component of the pain assessment provides the most reliable cue for determining the effectiveness of
interventions?
A) The client's behavior and facial expression
B) The client's self-report of pain using a numerical rating scale
C) The client's vital signs changes
D) The nurse's observation of the client's activity level
Correct Answer: B
Rationale: Pain is a subjective experience, and the client's self-report is the most reliable indicator of pain intensity. Behavioral observations and vital signs
can be influenced by many factors and may not accurately reflect pain. The numerical rating scale provides a consistent, quantifiable measure to evaluate
intervention effectiveness.
Question 11
A nurse is caring for a client with a central venous catheter. Which cue should alert the nurse to a possible catheter-related bloodstream infection?
, A) The catheter insertion site is clean and dry
B) The client's white blood cell count is 8,500/mm³
C) The client develops chills and fever 30 minutes after catheter flushing
D) The client reports mild discomfort at the catheter site
Correct Answer: C
Rationale: Chills and fever following catheter flushing suggest the presence of a biofilm or infection within the catheter lumen that is being dislodged into
the bloodstream. This is a classic presentation of catheter-related bloodstream infection. A clean insertion site and normal WBC are reassuring. Mild
discomfort may be expected.
Question 12
A nurse is assessing a client with suspected pulmonary embolism. Which assessment finding should the nurse recognize as the most significant cue?
A) Client reports sudden onset of pleuritic chest pain
B) Client's respiratory rate is 22 breaths per minute
C) Client's heart rate is 98 beats per minute
D) Client has mild anxiety
Correct Answer: A
Rationale: Sudden onset of pleuritic chest pain is a classic cue of pulmonary embolism, along with dyspnea, tachypnea, and hemoptysis. While tachycardia
and tachypnea are also signs, the sudden nature and quality of the chest pain are particularly significant. Anxiety may accompany but is less specific.
Question 13
A nurse is assessing a client with heart failure. Which cue indicates that the client's condition is worsening?
A) Client reports a 0.5 kg (1 lb) weight gain over 1 week
B) Client has 1+ pedal edema bilaterally
C) Client develops paroxysmal nocturnal dyspnea
D) Client's jugular veins are visible when lying flat
Correct Answer: C
Rationale: Paroxysmal nocturnal dyspnea (PND) is a significant cue of worsening heart failure, indicating fluid accumulation in the lungs during
recumbency. This represents a more advanced stage of heart failure than peripheral edema or mild weight gain. JVD when lying flat can be normal but
should be evaluated at 45 degrees.
Question 14
A nurse is reviewing a client's medication administration record. Which cue should alert the nurse to a potential medication error?
A) A medication is ordered for a different time than the client usually receives it
B) A medication is ordered that the client has taken previously without issues
C) The client's allergy list includes an allergy to the prescribed antibiotic
D) The medication is available in both tablet and liquid forms
Correct Answer: C
Rationale: A documented allergy to a prescribed medication is a critical safety cue that requires immediate action. Administering a medication to which a
client has a known allergy could result in a severe allergic reaction. Time changes, previous tolerance, and different formulations do not present the same
safety concern.
Question 15
A nurse is assessing a client who is 2 days postoperative. Which finding should the nurse recognize as a cue of potential venous thromboembolism?
