**THE TRIAGE DECISION SIMULATOR 2025/2026**
**1000+ CLINICAL JUDGMENT DRILLS FOR
NCLEX/ATI/HESI**
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Question 1
A nurse is caring for a client with chest pain. Which laboratory value is most specific for myocardial
infarction?
A. Troponin I
B. Creatine kinase-MB
C. Myoglobin
D. C-reactive protein
💫RATIONALE✔️✔️: Troponin I is highly specific to cardiac muscle and rises within 4-6 hours of MI.
💫ANSWER✔️✔️: A. Troponin I
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Question 2
A client with a new diagnosis of diabetes asks how often to check blood glucose. Which response is
best?
A. “Once daily before breakfast”
B. “Before meals and at bedtime”
C. “Only when you feel symptoms”
D. “Two hours after every meal”
💫RATIONALE✔️✔️: Checking before meals and bedtime provides pattern data to adjust insulin and diet.
💫ANSWER✔️✔️: B. “Before meals and at bedtime”
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Question 3
A nurse is assessing a client with a head injury. Which finding indicates Cushing’s triad?
A. Hypotension, bradycardia, tachypnea
B. Hypertension, bradycardia, irregular respirations
C. Hypertension, tachycardia, Cheyne-Stokes
D. Hypotension, tachycardia, apnea
💫RATIONALE✔️✔️: Cushing’s triad (HTN, bradycardia, irregular respirations) indicates increased ICP.
💫ANSWER✔️✔️: B. Hypertension, bradycardia, irregular respirations
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Question 4
A client with a history of venous stasis ulcers has a new order for compression stockings. Which
instruction is correct?
A. “Apply the stockings at bedtime”
B. “Remove stockings for 1 hour every 4 hours”
C. “Wear stockings during waking hours only”
D. “Apply lotion before putting on stockings”
💫RATIONALE✔️✔️: Compression stockings are worn during the day and removed at night to prevent skin
breakdown.
💫ANSWER✔️✔️: C. “Wear stockings during waking hours only”
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Question 5
A nurse is caring for a client with a new prescription for haloperidol. Which side effect requires
immediate intervention?
A. Dry mouth
, B. Drowsiness
C. Muscle rigidity and fever
D. Orthostatic hypotension
💫RATIONALE✔️✔️: Muscle rigidity with fever suggests neuroleptic malignant syndrome, a medical
emergency.
💫ANSWER✔️✔️: C. Muscle rigidity and fever
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Question 6
A client with a history of angina is prescribed nitroglycerin transdermal patch. Which instruction is
correct?
A. “Apply a new patch every 8 hours”
B. “Remove the patch for 10-12 hours each day”
C. “Shave the area before applying the patch”
D. “Apply heat over the patch to increase absorption”
💫RATIONALE✔️✔️: A nitrate-free interval of 10-12 hours prevents tolerance.
💫ANSWER✔️✔️: B. “Remove the patch for 10-12 hours each day”
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Question 7
A nurse is assessing a client with a suspected pulmonary embolism. Which finding is most common?
A. Hemoptysis
B. Pleuritic chest pain
C. Syncope
D. Fever
💫RATIONALE✔️✔️: Sudden pleuritic chest pain and dyspnea occur in >80% of pulmonary emboli.
💫ANSWER✔️✔️: B. Pleuritic chest pain
**1000+ CLINICAL JUDGMENT DRILLS FOR
NCLEX/ATI/HESI**
---
Question 1
A nurse is caring for a client with chest pain. Which laboratory value is most specific for myocardial
infarction?
A. Troponin I
B. Creatine kinase-MB
C. Myoglobin
D. C-reactive protein
💫RATIONALE✔️✔️: Troponin I is highly specific to cardiac muscle and rises within 4-6 hours of MI.
💫ANSWER✔️✔️: A. Troponin I
---
Question 2
A client with a new diagnosis of diabetes asks how often to check blood glucose. Which response is
best?
A. “Once daily before breakfast”
B. “Before meals and at bedtime”
C. “Only when you feel symptoms”
D. “Two hours after every meal”
💫RATIONALE✔️✔️: Checking before meals and bedtime provides pattern data to adjust insulin and diet.
💫ANSWER✔️✔️: B. “Before meals and at bedtime”
,---
Question 3
A nurse is assessing a client with a head injury. Which finding indicates Cushing’s triad?
A. Hypotension, bradycardia, tachypnea
B. Hypertension, bradycardia, irregular respirations
C. Hypertension, tachycardia, Cheyne-Stokes
D. Hypotension, tachycardia, apnea
💫RATIONALE✔️✔️: Cushing’s triad (HTN, bradycardia, irregular respirations) indicates increased ICP.
💫ANSWER✔️✔️: B. Hypertension, bradycardia, irregular respirations
---
Question 4
A client with a history of venous stasis ulcers has a new order for compression stockings. Which
instruction is correct?
A. “Apply the stockings at bedtime”
B. “Remove stockings for 1 hour every 4 hours”
C. “Wear stockings during waking hours only”
D. “Apply lotion before putting on stockings”
💫RATIONALE✔️✔️: Compression stockings are worn during the day and removed at night to prevent skin
breakdown.
💫ANSWER✔️✔️: C. “Wear stockings during waking hours only”
---
Question 5
A nurse is caring for a client with a new prescription for haloperidol. Which side effect requires
immediate intervention?
A. Dry mouth
, B. Drowsiness
C. Muscle rigidity and fever
D. Orthostatic hypotension
💫RATIONALE✔️✔️: Muscle rigidity with fever suggests neuroleptic malignant syndrome, a medical
emergency.
💫ANSWER✔️✔️: C. Muscle rigidity and fever
---
Question 6
A client with a history of angina is prescribed nitroglycerin transdermal patch. Which instruction is
correct?
A. “Apply a new patch every 8 hours”
B. “Remove the patch for 10-12 hours each day”
C. “Shave the area before applying the patch”
D. “Apply heat over the patch to increase absorption”
💫RATIONALE✔️✔️: A nitrate-free interval of 10-12 hours prevents tolerance.
💫ANSWER✔️✔️: B. “Remove the patch for 10-12 hours each day”
---
Question 7
A nurse is assessing a client with a suspected pulmonary embolism. Which finding is most common?
A. Hemoptysis
B. Pleuritic chest pain
C. Syncope
D. Fever
💫RATIONALE✔️✔️: Sudden pleuritic chest pain and dyspnea occur in >80% of pulmonary emboli.
💫ANSWER✔️✔️: B. Pleuritic chest pain
