ATI RN Concept-Based Assessment Proctored Newest Exam –
Level 3 Advanced Clinical Judgment: Complex Multisystem
Disorders, Critical Care, and High-Acuity Decision Making |
2026/2027 update
1. A nurse is caring for a client who has increased intracranial pressure following a
traumatic brain injury. Which finding should the nurse report to the provider immediately?
A. The client's blood pressure is 130/80 mm Hg with a heart rate of 88 beats per minute.
B. The client's pupils are equal and reactive to light bilaterally.
C. The client's Glasgow Coma Scale score is 14.
D. The client's blood pressure is 170/60 mm Hg with a heart rate of 52 beats per
minute.
Rationale: Widening pulse pressure (increasing systolic, decreasing diastolic) with
bradycardia (Cushing's triad) is a late sign of severely increased ICP and impending
herniation. This requires immediate intervention. The other findings are less critical.
Q2. A nurse is caring for a client who has septic shock and is receiving norepinephrine via
continuous infusion. Which finding indicates that the medication is having the desired
therapeutic effect?
A. The client's heart rate has decreased from 120 to 100 beats per minute.
B. The client's mean arterial pressure has increased from 55 to 70 mm Hg.
C. The client's urine output has decreased from 40 to 20 mL per hour.
D. The client's central venous pressure has decreased from 12 to 8 mm Hg.
Rationale: Norepinephrine is a vasopressor used to increase MAP in septic shock.
Target MAP is at least 65 mm Hg. Increased MAP indicates improved organ perfusion.
Decreasing urine output and decreasing CVP are not desired effects.
Q3. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS) and
is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which
finding indicates a complication of this therapy?
A. The client's oxygen saturation is 92 percent on FiO2 of 0.50.
B. The client's tidal volume is 450 mL with a plateau pressure of 25 cm H2O.
C. The client's blood pressure drops from 120/80 to 80/50 mm Hg.
,D. The client's PaCO2 is 40 mm Hg with a pH of 7.38.
Rationale: Hypotension is a complication of high PEEP, which reduces venous return
and cardiac output. This requires immediate evaluation and possible PEEP reduction.
Improved oxygenation, normal plateau pressure, and normal PaCO2 are desired findings.
Q4. A nurse is caring for a client who has a new diagnosis of status epilepticus. Which
action should the nurse take first?
A. Administer intravenous lorazepam as prescribed.
B. Place a padded tongue blade in the client's mouth.
C. Obtain a stat serum glucose level.
D. Apply soft wrist restraints to prevent injury.
Rationale: Status epilepticus is a medical emergency. First-line treatment is IV
benzodiazepines (lorazepam, diazepam) to stop seizure activity. Nothing should be placed
in the mouth. Glucose check can be done rapidly. Restraints are not appropriate during
active seizures.
Q5. A nurse is assessing a client who has a new diagnosis of increased intracranial
pressure. Which finding is the earliest indicator of neurological deterioration in this client?
A. Decerebrate posturing in response to painful stimuli.
B. Pupils that are fixed and dilated bilaterally.
C. A change in level of consciousness, such as lethargy or confusion.
D. Cushing's triad with hypertension and bradycardia.
Rationale: Change in LOC (restlessness, confusion, lethargy) is the earliest and most
sensitive indicator of increased ICP. Pupil changes, posturing, and Cushing's triad occur
later as ICP continues to rise.
Q6. A nurse is providing discharge teaching to a client who has a new prescription for
warfarin after a mechanical heart valve replacement. Which statement by the client
indicates correct understanding of this medication?
A. "I will take ibuprofen for headaches instead of acetaminophen."
B. "I will have my INR checked regularly and keep it within the target range of 2.5 to
3.5."
C. "I will eat a large spinach salad every day to keep my blood healthy."
D. "I will stop taking warfarin for three days before having my teeth cleaned."
Rationale: For mechanical heart valves, target INR is higher (2.5-3.5). Regular
,monitoring is essential. Ibuprofen increases bleeding risk. Consistent vitamin K intake is
important, not large variations. Warfarin should not be stopped without provider approval.
Q7. A nurse is caring for a client who has acute liver failure and is showing signs of hepatic
encephalopathy. Which medication prescription should the nurse administer to help reduce
ammonia levels?
A. Furosemide 40 mg intravenously.
B. Lactulose 30 mL orally every 4 to 6 hours.
C. Naloxone 0.4 mg intravenously.
D. Protamine sulfate 25 mg intravenously.
Rationale: Lactulose acidifies the colon, trapping ammonia as ammonium and
promoting its excretion in stool. This is first-line treatment for hepatic encephalopathy.
Furosemide is a diuretic. Naloxone reverses opioids. Protamine reverses heparin.
Q8. A nurse is assessing a client who has a new diagnosis of disseminated intravascular
coagulation (DIC) secondary to sepsis. Which laboratory finding should the nurse expect?
A. Elevated platelet count and prolonged bleeding time.
B. Decreased fibrinogen level and normal PT/INR.
C. Decreased platelet count, prolonged PT/INR, and low fibrinogen.
D. Normal platelet count with elevated D-dimer and prolonged aPTT.
Rationale: DIC causes consumption of clotting factors and platelets, leading to
thrombocytopenia, prolonged PT/INR and aPTT, low fibrinogen, and elevated D-dimer. All
coagulation studies are typically abnormal due to simultaneous clotting and bleeding.
Q9. A nurse is caring for a client who has a chest tube connected to a closed drainage
system following a pneumothorax. Which finding should the nurse report to the provider
immediately?
A. Intermittent bubbling in the water seal chamber during exhalation and coughing.
B. Continuous gentle bubbling in the suction control chamber.
C. 200 mL of serosanguineous drainage in the collection chamber over 4 hours.
D. Constant bubbling in the water seal chamber with no fluctuation (tidaling).
Rationale: Constant bubbling in the water seal chamber indicates an air leak, which can
prevent lung re-expansion. Tidaling (fluctuation) is expected. Continuous bubbling in suction
control is normal when wall suction is applied. Small to moderate drainage is expected.
, Q10. A nurse is caring for a client who has a new diagnosis of acute myocardial infarction
and is receiving thrombolytic therapy. Which finding should the nurse report to the provider
as a potential complication of this therapy?
A. The client reports chest pain that is relieved by nitroglycerin.
B. The client's ST-segment elevations have resolved on ECG.
C. The client reports a sudden severe headache and has a blood pressure of 180/100
mm Hg.
D. The client's cardiac troponin level has peaked and is now decreasing.
Rationale: Sudden severe headache and hypertension after thrombolytics suggest
intracranial hemorrhage, a life-threatening complication. Chest pain relief and ST-segment
resolution indicate successful reperfusion. Decreasing troponin is expected after the peak.
Q11. A nurse is assessing a client who has a new diagnosis of myasthenia gravis and is
experiencing a myasthenic crisis. Which finding distinguishes a myasthenic crisis from a
cholinergic crisis?
A. The client has muscle weakness that improves with rest and worsens with activity.
B. The client has excessive salivation, diaphoresis, and miosis.
C. The client's muscle strength improves after administration of edrophonium
(Tensilon test).
D. The client has fasciculations and muscle cramps.
Rationale: A Tensilon test (edrophonium) is used to differentiate myasthenic crisis
(improves with edrophonium) from cholinergic crisis (worsens or shows no improvement).
Cholinergic crisis causes muscarinic effects (salivation, miosis, diaphoresis). Muscle
weakness with activity is characteristic of myasthenia gravis but does not differentiate the
two crises.
Q12. A nurse is caring for a client who has a new diagnosis of acute respiratory distress
syndrome (ARDS). Which finding is characteristic of this condition?
A. Respiratory alkalosis with a PaCO2 of 30 mm Hg.
B. Oxygen saturation of 90 percent on room air.
C. Refractory hypoxemia that does not improve significantly with increased oxygen.
D. Bilateral crackles that clear with coughing and deep breathing.
Rationale: ARDS is characterized by refractory hypoxemia (PaO2/FiO2 ratio <300) that
does not respond well to supplemental oxygen alone due to alveolar damage and shunting.
PEEP and mechanical ventilation are often required. Crackles do not clear with coughing in
ARDS.
Level 3 Advanced Clinical Judgment: Complex Multisystem
Disorders, Critical Care, and High-Acuity Decision Making |
2026/2027 update
1. A nurse is caring for a client who has increased intracranial pressure following a
traumatic brain injury. Which finding should the nurse report to the provider immediately?
A. The client's blood pressure is 130/80 mm Hg with a heart rate of 88 beats per minute.
B. The client's pupils are equal and reactive to light bilaterally.
C. The client's Glasgow Coma Scale score is 14.
D. The client's blood pressure is 170/60 mm Hg with a heart rate of 52 beats per
minute.
Rationale: Widening pulse pressure (increasing systolic, decreasing diastolic) with
bradycardia (Cushing's triad) is a late sign of severely increased ICP and impending
herniation. This requires immediate intervention. The other findings are less critical.
Q2. A nurse is caring for a client who has septic shock and is receiving norepinephrine via
continuous infusion. Which finding indicates that the medication is having the desired
therapeutic effect?
A. The client's heart rate has decreased from 120 to 100 beats per minute.
B. The client's mean arterial pressure has increased from 55 to 70 mm Hg.
C. The client's urine output has decreased from 40 to 20 mL per hour.
D. The client's central venous pressure has decreased from 12 to 8 mm Hg.
Rationale: Norepinephrine is a vasopressor used to increase MAP in septic shock.
Target MAP is at least 65 mm Hg. Increased MAP indicates improved organ perfusion.
Decreasing urine output and decreasing CVP are not desired effects.
Q3. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS) and
is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which
finding indicates a complication of this therapy?
A. The client's oxygen saturation is 92 percent on FiO2 of 0.50.
B. The client's tidal volume is 450 mL with a plateau pressure of 25 cm H2O.
C. The client's blood pressure drops from 120/80 to 80/50 mm Hg.
,D. The client's PaCO2 is 40 mm Hg with a pH of 7.38.
Rationale: Hypotension is a complication of high PEEP, which reduces venous return
and cardiac output. This requires immediate evaluation and possible PEEP reduction.
Improved oxygenation, normal plateau pressure, and normal PaCO2 are desired findings.
Q4. A nurse is caring for a client who has a new diagnosis of status epilepticus. Which
action should the nurse take first?
A. Administer intravenous lorazepam as prescribed.
B. Place a padded tongue blade in the client's mouth.
C. Obtain a stat serum glucose level.
D. Apply soft wrist restraints to prevent injury.
Rationale: Status epilepticus is a medical emergency. First-line treatment is IV
benzodiazepines (lorazepam, diazepam) to stop seizure activity. Nothing should be placed
in the mouth. Glucose check can be done rapidly. Restraints are not appropriate during
active seizures.
Q5. A nurse is assessing a client who has a new diagnosis of increased intracranial
pressure. Which finding is the earliest indicator of neurological deterioration in this client?
A. Decerebrate posturing in response to painful stimuli.
B. Pupils that are fixed and dilated bilaterally.
C. A change in level of consciousness, such as lethargy or confusion.
D. Cushing's triad with hypertension and bradycardia.
Rationale: Change in LOC (restlessness, confusion, lethargy) is the earliest and most
sensitive indicator of increased ICP. Pupil changes, posturing, and Cushing's triad occur
later as ICP continues to rise.
Q6. A nurse is providing discharge teaching to a client who has a new prescription for
warfarin after a mechanical heart valve replacement. Which statement by the client
indicates correct understanding of this medication?
A. "I will take ibuprofen for headaches instead of acetaminophen."
B. "I will have my INR checked regularly and keep it within the target range of 2.5 to
3.5."
C. "I will eat a large spinach salad every day to keep my blood healthy."
D. "I will stop taking warfarin for three days before having my teeth cleaned."
Rationale: For mechanical heart valves, target INR is higher (2.5-3.5). Regular
,monitoring is essential. Ibuprofen increases bleeding risk. Consistent vitamin K intake is
important, not large variations. Warfarin should not be stopped without provider approval.
Q7. A nurse is caring for a client who has acute liver failure and is showing signs of hepatic
encephalopathy. Which medication prescription should the nurse administer to help reduce
ammonia levels?
A. Furosemide 40 mg intravenously.
B. Lactulose 30 mL orally every 4 to 6 hours.
C. Naloxone 0.4 mg intravenously.
D. Protamine sulfate 25 mg intravenously.
Rationale: Lactulose acidifies the colon, trapping ammonia as ammonium and
promoting its excretion in stool. This is first-line treatment for hepatic encephalopathy.
Furosemide is a diuretic. Naloxone reverses opioids. Protamine reverses heparin.
Q8. A nurse is assessing a client who has a new diagnosis of disseminated intravascular
coagulation (DIC) secondary to sepsis. Which laboratory finding should the nurse expect?
A. Elevated platelet count and prolonged bleeding time.
B. Decreased fibrinogen level and normal PT/INR.
C. Decreased platelet count, prolonged PT/INR, and low fibrinogen.
D. Normal platelet count with elevated D-dimer and prolonged aPTT.
Rationale: DIC causes consumption of clotting factors and platelets, leading to
thrombocytopenia, prolonged PT/INR and aPTT, low fibrinogen, and elevated D-dimer. All
coagulation studies are typically abnormal due to simultaneous clotting and bleeding.
Q9. A nurse is caring for a client who has a chest tube connected to a closed drainage
system following a pneumothorax. Which finding should the nurse report to the provider
immediately?
A. Intermittent bubbling in the water seal chamber during exhalation and coughing.
B. Continuous gentle bubbling in the suction control chamber.
C. 200 mL of serosanguineous drainage in the collection chamber over 4 hours.
D. Constant bubbling in the water seal chamber with no fluctuation (tidaling).
Rationale: Constant bubbling in the water seal chamber indicates an air leak, which can
prevent lung re-expansion. Tidaling (fluctuation) is expected. Continuous bubbling in suction
control is normal when wall suction is applied. Small to moderate drainage is expected.
, Q10. A nurse is caring for a client who has a new diagnosis of acute myocardial infarction
and is receiving thrombolytic therapy. Which finding should the nurse report to the provider
as a potential complication of this therapy?
A. The client reports chest pain that is relieved by nitroglycerin.
B. The client's ST-segment elevations have resolved on ECG.
C. The client reports a sudden severe headache and has a blood pressure of 180/100
mm Hg.
D. The client's cardiac troponin level has peaked and is now decreasing.
Rationale: Sudden severe headache and hypertension after thrombolytics suggest
intracranial hemorrhage, a life-threatening complication. Chest pain relief and ST-segment
resolution indicate successful reperfusion. Decreasing troponin is expected after the peak.
Q11. A nurse is assessing a client who has a new diagnosis of myasthenia gravis and is
experiencing a myasthenic crisis. Which finding distinguishes a myasthenic crisis from a
cholinergic crisis?
A. The client has muscle weakness that improves with rest and worsens with activity.
B. The client has excessive salivation, diaphoresis, and miosis.
C. The client's muscle strength improves after administration of edrophonium
(Tensilon test).
D. The client has fasciculations and muscle cramps.
Rationale: A Tensilon test (edrophonium) is used to differentiate myasthenic crisis
(improves with edrophonium) from cholinergic crisis (worsens or shows no improvement).
Cholinergic crisis causes muscarinic effects (salivation, miosis, diaphoresis). Muscle
weakness with activity is characteristic of myasthenia gravis but does not differentiate the
two crises.
Q12. A nurse is caring for a client who has a new diagnosis of acute respiratory distress
syndrome (ARDS). Which finding is characteristic of this condition?
A. Respiratory alkalosis with a PaCO2 of 30 mm Hg.
B. Oxygen saturation of 90 percent on room air.
C. Refractory hypoxemia that does not improve significantly with increased oxygen.
D. Bilateral crackles that clear with coughing and deep breathing.
Rationale: ARDS is characterized by refractory hypoxemia (PaO2/FiO2 ratio <300) that
does not respond well to supplemental oxygen alone due to alveolar damage and shunting.
PEEP and mechanical ventilation are often required. Crackles do not clear with coughing in
ARDS.
