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Exam (elaborations)

ATI RN Concept Based Assessment Level 2 Proctored Exam Questions and Answers with Rationales

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ATI RN Concept Based Assessment Level 2 Proctored Exam Questions and Answers with Rationales

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ATI RN Concept Based Assessment Level 2 Proctored Exam
Questions and Answers with Rationales
Question 1: The nurse is evaluating a plan of care focused on Hypocalcemia. Which finding is most useful for
determining whether the plan is effective?
A. neuromuscular irritability, airway status, QT interval, and serum calcium
B. cardiac rhythm, serum potassium, renal function, and response to potassium-lowering therapy
C. blood pressure, heart rate, urine output, mental status, daily weight, and intake and output
D. serum calcium, urine output, mental status, cardiac rhythm, and signs of renal calculi
Answer: A. neuromuscular irritability, airway status, QT interval, and serum calcium
Rationale: The most useful evaluation finding is neuromuscular irritability, airway status, QT interval, and serum calcium. This
finding directly tracks the physiologic problem because low ionized calcium increases neuromuscular excitability and can cause
tetany, seizures, laryngospasm, and qt prolongation. The other findings may be important in selected clients, but they are less
directly linked to the expected response for Hypocalcemia. Trend this finding with the client's symptoms and overall clinical status
rather than relying on a single isolated value.

Question 2: A nurse is caring for a client who has frequent loose stools, thirst, dry mucous membranes, orthostatic
dizziness, and decreasing urine output. Which action should the nurse prioritize?
A. Evaluate perfusion and medication exposures, monitor urine output closely, and address the reversible cause
B. Assess hydration and hemodynamic status, replace prescribed fluids and electrolytes, and identify the underlying cause
C. Perform a focused abdominal and rectal assessment as appropriate and initiate ordered disimpaction measures
D. Monitor volume status, electrolytes, blood pressure, and prescribed renal therapies while preventing further nephron injury
Answer: B. Assess hydration and hemodynamic status, replace prescribed fluids and electrolytes, and identify the
underlying cause
Rationale: Assess hydration and hemodynamic status, replace prescribed fluids and electrolytes, and identify the underlying cause is
the priority because restoring circulating volume and monitoring losses reduce the risk of hypotension, kidney injury, and
electrolyte imbalance. This action addresses the most immediate threat associated with Acute diarrhea with volume loss. The other
actions may be useful for other conditions or at a later stage, but they do not address the highest-priority need in this presentation.
After intervening, the nurse should reassess stool frequency, orthostatic vital signs, urine output, weight, and electrolyte values.
ATI RN Concept-Based Assessment Level 2 - Original Practice Exam Page 1

Question 3: A nurse assesses a client who has severe escalating pain out of proportion to the injury, pain with
passive stretch, paresthesia, and tense swelling beneath a cast. Which clinical problem or care need is most
consistent with this presentation?
A. Safe walker use
B. Skeletal traction care
C. Safe cane use
D. Compartment syndrome after fracture
Answer: D. Compartment syndrome after fracture
Rationale: This pattern is most consistent with Compartment syndrome after fracture. Rising pressure within a closed fascial
compartment impairs capillary perfusion and can cause irreversible muscle and nerve ischemia. The alternative conditions typically
produce a different combination of assessment findings, laboratory changes, or time course. Recognizing the pattern helps the
nurse promptly notify the surgical team immediately and prepare for urgent pressure-relieving intervention while maintaining the
limb near heart level.

,Question 4: A nurse is caring for a client who has increased alertness and mild tension before a new experience
while the client remains able to learn and solve problems. Which action should the nurse prioritize?
A. Acknowledge the concern, provide clear information, and use the client's increased attention to support problem solving
B. Stay with the client, reduce environmental stimulation, use brief simple statements, and address immediate safety needs
C. Reinforce the workable plan and help the client identify specific next steps, resources, and barriers
D. Assess safety and functioning and support evidence-based trauma-focused treatment while avoiding coercive discussion of
trauma details
Answer: A. Acknowledge the concern, provide clear information, and use the client's increased attention to support
problem solving
Rationale: Acknowledge the concern, provide clear information, and use the client's increased attention to support problem solving is
the priority because supportive information and coping strategies can channel the arousal into effective learning and planning. This
action addresses the most immediate threat associated with Mild anxiety. The other actions may be useful for other conditions or at
a later stage, but they do not address the highest-priority need in this presentation. After intervening, the nurse should reassess
ability to concentrate, ask questions, learn new information, and return to baseline after the stressor. ATI RN Concept-Based
Assessment Level 2 - Original Practice Exam Page 2

Question 5: A nurse is caring for a client who has headache, nausea, confusion, muscle cramps, and a serum
sodium below the reference range. Which action should the nurse prioritize?
A. Institute safety precautions, assess for laryngospasm and dysrhythmias, and administer prescribed calcium replacement
B. Assess perfusion and begin prescribed isotonic fluid replacement while tracking ongoing losses
C. Perform frequent neurologic assessments, institute seizure precautions when indicated, and correct sodium and water balance
as prescribed
D. Institute cardiac and seizure precautions as indicated and administer prescribed magnesium replacement
Answer: C. Perform frequent neurologic assessments, institute seizure precautions when indicated, and correct sodium
and water balance as prescribed
Rationale: Perform frequent neurologic assessments, institute seizure precautions when indicated, and correct sodium and water
balance as prescribed is the priority because neurologic deterioration and seizures are major risks, and overly rapid correction can
also cause serious neurologic injury. This action addresses the most immediate threat associated with Hyponatremia. The other
actions may be useful for other conditions or at a later stage, but they do not address the highest-priority need in this presentation.
After intervening, the nurse should reassess neurologic status and the rate and direction of serum sodium correction.

Question 6: A nurse is reinforcing teaching related to Severe accidental hypothermia. Which client statement
indicates correct understanding?
A. I will keep exercising through dizziness and nausea in extreme heat to maintain conditioning.
B. I will rub and vigorously massage the limbs of a severely hypothermic person to warm them faster.
C. I understand that a severely cold person with confusion or slowed breathing needs emergency care and gentle handling.
D. I will assume confusion during heat exposure is harmless if the person is still sweating.
Answer: C. I understand that a severely cold person with confusion or slowed breathing needs emergency care and
gentle handling.
Rationale: The statement "I understand that a severely cold person with confusion or slowed breathing needs emergency care and
gentle handling." reflects correct self-management for Severe accidental hypothermia. This teaching is important because altered
mental status and slowed vital functions indicate a medical emergency rather than uncomplicated cold discomfort. The other
statements either conflict with safe care, delay needed evaluation, or apply advice that does not fit this condition. The nurse should
use teach-back and clarify when the client should contact the health care team or seek urgent care. ATI RN Concept-Based
Assessment Level 2 - Original Practice Exam Page 3

,Question 7: A nurse assesses a client who has fatigue, weight loss, hypotension, hyponatremia, hyperkalemia, and
weakness with inadequate cortisol production. Which clinical problem or care need is most consistent with this
presentation?
A. Metabolic syndrome
B. Adrenal insufficiency
C. Hyperosmolar hyperglycemic state
D. Primary hypothyroidism
Answer: B. Adrenal insufficiency
Rationale: This pattern is most consistent with Adrenal insufficiency. Cortisol deficiency reduces vascular responsiveness and impairs
glucose and stress regulation, while mineralocorticoid deficiency may cause sodium loss and hyperkalemia. The alternative
conditions typically produce a different combination of assessment findings, laboratory changes, or time course. Recognizing the
pattern helps the nurse promptly administer prescribed glucocorticoid replacement, support blood pressure and volume, and
increase steroid coverage during physiologic stress as ordered.

Question 8: A nurse is reinforcing teaching related to Metabolic syndrome. Which client statement indicates
correct understanding?
A. I will ignore a glucose below 70 mg/dL if I am still awake and talking.
B. I will focus on regular activity and achievable nutrition changes rather than relying on a short-term restrictive diet.
C. I will stop all insulin during illness whenever I cannot eat normally.
D. I will treat severe confusion from high glucose at home without seeking urgent help.
Answer: B. I will focus on regular activity and achievable nutrition changes rather than relying on a short-term
restrictive diet.
Rationale: The statement "I will focus on regular activity and achievable nutrition changes rather than relying on a short-term
restrictive diet." reflects correct self-management for Metabolic syndrome. This teaching is important because sustainable activity
and nutrition changes are more likely to improve cardiometabolic risk than brief extreme dieting. The other statements either
conflict with safe care, delay needed evaluation, or apply advice that does not fit this condition. The nurse should use teach-back
and clarify when the client should contact the health care team or seek urgent care. ATI RN Concept-Based Assessment Level 2 -
Original Practice Exam Page 4

Question 9: A nurse is caring for a client who has unilateral lower-extremity weakness with adequate balance to
ambulate using a single-point cane. Which action should the nurse prioritize?
A. Teach the client to hold the cane on the stronger side and advance it with the weaker leg
B. Manage pain, assess neurovascular status, begin prescribed early ambulation, and follow the surgeon's movement precautions
C. Maintain continuous prescribed traction with weights hanging freely and perform frequent neurovascular and pin-site
assessments
D. Promote fall prevention, weight-bearing and resistance activity as appropriate, adequate calcium and vitamin D, and
prescribed bone-directed therapy
Answer: A. Teach the client to hold the cane on the stronger side and advance it with the weaker leg
Rationale: Teach the client to hold the cane on the stronger side and advance it with the weaker leg is the priority because proper
sequencing improves balance and allows the cane to share weight as the weaker leg advances. This action addresses the most
immediate threat associated with Safe cane use. The other actions may be useful for other conditions or at a later stage, but they do
not address the highest-priority need in this presentation. After intervening, the nurse should reassess gait stability, correct cane
height and sequence, fatigue, and absence of falls.

, Question 10: A nurse is reinforcing teaching related to Chronic venous insufficiency. Which client statement
indicates correct understanding?
A. I will elevate my legs when resting and use prescribed compression consistently if my arterial circulation has been assessed
as adequate.
B. I will take extra blood-pressure medicine whenever one reading is high without following my treatment plan.
C. I will stop prescribed antiplatelet or anticoagulant therapy on my own when bruising appears.
D. I will wait at home for persistent new chest pressure to go away before seeking emergency care.
Answer: A. I will elevate my legs when resting and use prescribed compression consistently if my arterial circulation
has been assessed as adequate.
Rationale: The statement "I will elevate my legs when resting and use prescribed compression consistently if my arterial circulation
has been assessed as adequate." reflects correct self-management for Chronic venous insufficiency. This teaching is important
because consistent elevation and compression can reduce edema and recurrence of venous ulcers. The other statements either
conflict with safe care, delay needed evaluation, or apply advice that does not fit this condition. The nurse should use teach-back
and clarify when the client should contact the health care team or seek urgent care. ATI RN Concept-Based Assessment Level 2 -
Original Practice Exam Page 5

Question 11: The nurse is evaluating a plan of care focused on Mechanical bowel obstruction. Which finding is
most useful for determining whether the plan is effective?
A. abdominal distention, pain, emesis, bowel function, urine output, and electrolyte trends
B. pain relief, urine output, passage or imaging of the stone, and absence of fever or worsening obstruction
C. weight trend, blood pressure, potassium, bicarbonate, hemoglobin, and estimated glomerular filtration rate
D. declining temperature, improving flank pain, stable blood pressure, and adequate urine output
Answer: A. abdominal distention, pain, emesis, bowel function, urine output, and electrolyte trends
Rationale: The most useful evaluation finding is abdominal distention, pain, emesis, bowel function, urine output, and electrolyte
trends. This finding directly tracks the physiologic problem because a mechanical blockage prevents intestinal contents and gas
from moving normally and can cause proximal distention and fluid shifts. The other findings may be important in selected clients,
but they are less directly linked to the expected response for Mechanical bowel obstruction. Trend this finding with the client's
symptoms and overall clinical status rather than relying on a single isolated value.

Question 12: A nurse is reinforcing teaching related to Surgical site infection. Which client statement indicates
correct understanding?
A. I will wash my hands before touching the incision and report new drainage, fever, or spreading redness.
B. I will reuse soiled wound supplies if they still look clean enough.
C. I will stop an antibiotic as soon as fever and pain improve even if doses remain.
D. I will ignore a new fever during severe neutropenia unless I also have pus or redness.
Answer: A. I will wash my hands before touching the incision and report new drainage, fever, or spreading redness.
Rationale: The statement "I will wash my hands before touching the incision and report new drainage, fever, or spreading redness."
reflects correct self-management for Surgical site infection. This teaching is important because clean hand practices and early
reporting help prevent contamination and permit prompt treatment of abnormal wound changes. The other statements either
conflict with safe care, delay needed evaluation, or apply advice that does not fit this condition. The nurse should use teach-back
and clarify when the client should contact the health care team or seek urgent care. ATI RN Concept-Based Assessment Level 2 -
Original Practice Exam Page 6

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