ATI Fundamentals Clinical Judgment
Review: Priority, Delegation & First-
Action Questions and answers with
rationales
1. A nurse receives report on four clients. Which client should the
nurse assess first?
A. A client with chronic arthritis reporting pain 6/10
B. A client with pneumonia who has an oxygen saturation of 89%
C. A client with diabetes whose blood glucose is 145 mg/dL
D. A client awaiting discharge instructions
Answer: B. A client with pneumonia who has an oxygen saturation
of 89%
Rationale: Oxygenation is an immediate physiologic priority. An
oxygen saturation of 89% in a client with pneumonia can indicate
impaired gas exchange and requires prompt assessment and
intervention.
2. A client suddenly reports difficulty breathing. What is the nurse's
priority action?
A. Obtain the client's temperature
B. Ask about the onset of symptoms
C. Assess the client's airway and breathing
D. Document the client's complaint
Answer: C. Assess the client's airway and breathing
,Rationale: Airway and breathing take priority during an acute change
in condition. The nurse should immediately determine whether the
airway is patent and whether ventilation is adequate.
3. Which client should the nurse see first?
A. A client with a new prescription for oral antibiotics
B. A client with a respiratory rate of 8/min after receiving an opioid
C. A client requesting assistance with bathing
D. A client reporting constipation for 2 days
Answer: B. A client with a respiratory rate of 8/min after receiving
an opioid
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min represents a potentially life-threatening
airway/breathing problem.
4. A nurse finds a client lying on the floor beside the bed. What
should the nurse do first?
A. Complete an incident report
B. Notify the provider
C. Assess the client for injury
D. Return the client to bed
Answer: C. Assess the client for injury
Rationale: The nurse must first assess the client's condition, including
airway, breathing, circulation, level of consciousness, and possible
injuries, before moving the client.
5. Which finding requires immediate intervention?
,A. Blood pressure 128/76 mm Hg
B. Pulse 84/min
C. Respiratory rate 30/min with dyspnea
D. Temperature 37.2°C (99°F)
Answer: C. Respiratory rate 30/min with dyspnea
Rationale: Tachypnea accompanied by dyspnea indicates respiratory
compromise and requires immediate assessment.
6. A client reports chest pressure and nausea. Which action should
the nurse take first?
A. Obtain a 12-lead ECG
B. Ask the client about dietary intake
C. Administer an antacid
D. Encourage ambulation
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pressure with nausea can indicate acute coronary
syndrome. Rapid cardiac assessment, including an ECG, is a priority.
7. Which client should the nurse assess first?
A. A client with a headache rated 5/10
B. A client with new unilateral weakness
C. A client with chronic back pain
D. A client requesting a sleeping medication
Answer: B. A client with new unilateral weakness
Rationale: New unilateral weakness can indicate an acute stroke.
Rapid recognition and intervention are essential.
, 8. A client becomes confused and restless. What should the nurse
assess first?
A. Oxygen saturation
B. Bowel sounds
C. Skin turgor
D. Appetite
Answer: A. Oxygen saturation
Rationale: Acute confusion and restlessness can be early signs of
hypoxemia. Oxygenation should be assessed promptly.
9. Which finding indicates the greatest need for immediate
intervention?
A. Urine output of 40 mL/hr
B. Capillary refill of 2 seconds
C. New stridor
D. Temperature of 38°C (100.4°F)
Answer: C. New stridor
Rationale: Stridor indicates upper-airway obstruction and can rapidly
become life-threatening.
10. A client has a sudden change in level of consciousness. What is
the nurse's first action?
A. Check the client's blood glucose
B. Call the family
C. Complete documentation
D. Offer oral fluids
Answer: A. Check the client's blood glucose
Review: Priority, Delegation & First-
Action Questions and answers with
rationales
1. A nurse receives report on four clients. Which client should the
nurse assess first?
A. A client with chronic arthritis reporting pain 6/10
B. A client with pneumonia who has an oxygen saturation of 89%
C. A client with diabetes whose blood glucose is 145 mg/dL
D. A client awaiting discharge instructions
Answer: B. A client with pneumonia who has an oxygen saturation
of 89%
Rationale: Oxygenation is an immediate physiologic priority. An
oxygen saturation of 89% in a client with pneumonia can indicate
impaired gas exchange and requires prompt assessment and
intervention.
2. A client suddenly reports difficulty breathing. What is the nurse's
priority action?
A. Obtain the client's temperature
B. Ask about the onset of symptoms
C. Assess the client's airway and breathing
D. Document the client's complaint
Answer: C. Assess the client's airway and breathing
,Rationale: Airway and breathing take priority during an acute change
in condition. The nurse should immediately determine whether the
airway is patent and whether ventilation is adequate.
3. Which client should the nurse see first?
A. A client with a new prescription for oral antibiotics
B. A client with a respiratory rate of 8/min after receiving an opioid
C. A client requesting assistance with bathing
D. A client reporting constipation for 2 days
Answer: B. A client with a respiratory rate of 8/min after receiving
an opioid
Rationale: Opioids can cause respiratory depression. A respiratory
rate of 8/min represents a potentially life-threatening
airway/breathing problem.
4. A nurse finds a client lying on the floor beside the bed. What
should the nurse do first?
A. Complete an incident report
B. Notify the provider
C. Assess the client for injury
D. Return the client to bed
Answer: C. Assess the client for injury
Rationale: The nurse must first assess the client's condition, including
airway, breathing, circulation, level of consciousness, and possible
injuries, before moving the client.
5. Which finding requires immediate intervention?
,A. Blood pressure 128/76 mm Hg
B. Pulse 84/min
C. Respiratory rate 30/min with dyspnea
D. Temperature 37.2°C (99°F)
Answer: C. Respiratory rate 30/min with dyspnea
Rationale: Tachypnea accompanied by dyspnea indicates respiratory
compromise and requires immediate assessment.
6. A client reports chest pressure and nausea. Which action should
the nurse take first?
A. Obtain a 12-lead ECG
B. Ask the client about dietary intake
C. Administer an antacid
D. Encourage ambulation
Answer: A. Obtain a 12-lead ECG
Rationale: Chest pressure with nausea can indicate acute coronary
syndrome. Rapid cardiac assessment, including an ECG, is a priority.
7. Which client should the nurse assess first?
A. A client with a headache rated 5/10
B. A client with new unilateral weakness
C. A client with chronic back pain
D. A client requesting a sleeping medication
Answer: B. A client with new unilateral weakness
Rationale: New unilateral weakness can indicate an acute stroke.
Rapid recognition and intervention are essential.
, 8. A client becomes confused and restless. What should the nurse
assess first?
A. Oxygen saturation
B. Bowel sounds
C. Skin turgor
D. Appetite
Answer: A. Oxygen saturation
Rationale: Acute confusion and restlessness can be early signs of
hypoxemia. Oxygenation should be assessed promptly.
9. Which finding indicates the greatest need for immediate
intervention?
A. Urine output of 40 mL/hr
B. Capillary refill of 2 seconds
C. New stridor
D. Temperature of 38°C (100.4°F)
Answer: C. New stridor
Rationale: Stridor indicates upper-airway obstruction and can rapidly
become life-threatening.
10. A client has a sudden change in level of consciousness. What is
the nurse's first action?
A. Check the client's blood glucose
B. Call the family
C. Complete documentation
D. Offer oral fluids
Answer: A. Check the client's blood glucose
