ATI Clinical Judgment Assessment | NGN Clinical Judgment Practice Exam | Next
Generation Nursing (NGN) Clinical Decision-Making Questions & Rationales |
ATI RN Clinical Judgment Comprehensive Review | Nursing Process &
Prioritization Practice Test | Cue Recognition, Analysis & Hypothesis Generation
| Safe Patient Care, Clinical Reasoning & Decision-Making Study Guide | NCLEX-
RN NGN Preparation Resource | Updated Practice Assessment with Detailed
Answer Explanations | Comprehensive Nursing Clinical Judgment Review for
Exam Success
Cardiovascular & Respiratory
Question 1
A nurse is assessing a client with heart failure. Which finding indicates worsening
fluid overload?
A. Weight loss of 1 lb in 24 hours
B. Jugular venous distention
C. Dry, hacking cough
D. Blood pressure 110/70 mmHg
Answer: B. Jugular venous distention
Rationale:
• A. Weight loss of 1 lb in 24 hours: This indicates improvement, not
worsening. Weight gain (2-3 lbs in 24 hours) would indicate fluid overload.
• B. Jugular venous distention: CORRECT. JVD is a hallmark sign of right-sided
heart failure and worsening fluid volume overload, indicating increased
central venous pressure.
• C. Dry, hacking cough: This is more associated with ACE inhibitor use
(angioedema) or early pulmonary congestion, but JVD is a more direct
indicator of fluid overload.
• D. Blood pressure 110/70 mmHg: This is a normal blood pressure and does
not indicate worsening fluid status.
,Question 2
A client with pneumonia has a SpO2 of 89% on room air. What is the nurse's
priority action?
A. Apply oxygen at 2 L/min via nasal cannula
B. Encourage deep breathing and coughing
C. Notify the provider immediately
D. Position the client in high-Fowler's position
Answer: A. Apply oxygen at 2 L/min via nasal cannula
Rationale:
• A. Apply oxygen at 2 L/min via nasal cannula: CORRECT. The priority is to
correct hypoxemia. Oxygen administration is the immediate intervention
for a low SpO2.
• B. Encourage deep breathing and coughing: This is important but not the
priority. The client needs supplemental oxygen first to correct the hypoxia.
• C. Notify the provider immediately: While the provider should be notified,
the nurse must first intervene to improve oxygenation.
• D. Position the client in high-Fowler's position: This is helpful to improve
lung expansion but is not the priority over oxygen administration.
Question 3
A nurse is caring for a client 2 hours after a cardiac catheterization via the femoral
artery. Which finding requires immediate action?
A. Hematoma at the insertion site
B. Pedal pulses palpable bilaterally
C. Client reports mild back pain
D. Blood pressure 118/76 mmHg
Answer: A. Hematoma at the insertion site
Rationale:
, • A. Hematoma at the insertion site: CORRECT. A growing hematoma
indicates bleeding at the puncture site and can lead to significant blood loss
or pseudoaneurysm. This requires immediate intervention.
• B. Pedal pulses palpable bilaterally: This is an expected finding indicating
good perfusion.
• C. Client reports mild back pain: This is common after lying flat and is not
immediately concerning.
• D. Blood pressure 118/76 mmHg: This is a stable blood pressure.
Question 4
A client is prescribed digoxin for heart failure. Which finding indicates digoxin
toxicity?
A. Heart rate 62 bpm
B. Anorexia and nausea
C. Blood pressure 120/80 mmHg
D. Urine output 50 mL/hr
Answer: B. Anorexia and nausea
Rationale:
• A. Heart rate 62 bpm: This is a normal heart rate. Bradycardia (HR < 60) is a
sign of digoxin toxicity, but this rate is not concerning.
• B. Anorexia and nausea: CORRECT. Gastrointestinal symptoms (nausea,
vomiting, anorexia) are early signs of digoxin toxicity, along with visual
disturbances (yellow-green halos) and cardiac dysrhythmias.
• C. Blood pressure 120/80 mmHg: This is normal.
• D. Urine output 50 mL/hr: This is adequate urine output.
Question 5
A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The nurse is
concerned about which complication?
, A. Oxygen toxicity
B. Suppression of hypoxic drive
C. Carbon dioxide retention
D. Nasal mucosal drying
Answer: B. Suppression of hypoxic drive
Rationale:
• A. Oxygen toxicity: This is a concern with high concentrations of oxygen
over long periods, but the rate of 4 L/min is not typically toxic.
• B. Suppression of hypoxic drive: CORRECT. Clients with COPD may rely on
hypoxic drive to stimulate breathing. High-flow oxygen can suppress this
drive, leading to hypoventilation and respiratory acidosis. Oxygen should be
titrated to maintain SpO2 of 88-92%.
• C. Carbon dioxide retention: This is the result of suppressing the hypoxic
drive, not the direct complication.
• D. Nasal mucosal drying: This is a minor side effect, not the primary
concern.
Question 6
A nurse is assessing a client with pericarditis. Which finding is characteristic?
A. Pain relieved by lying flat
B. Friction rub heard at the left sternal border
C. Pain worsened by sitting forward
D. Bradycardia
Answer: B. Friction rub heard at the left sternal border
Rationale:
• A. Pain relieved by lying flat: This is incorrect. Pericardial pain is worsened
by lying flat and relieved by sitting forward (leaning forward).
• B. Friction rub heard at the left sternal border: CORRECT. A pericardial
friction rub is a classic finding in pericarditis, heard best at the left lower
sternal border with the client leaning forward.
Generation Nursing (NGN) Clinical Decision-Making Questions & Rationales |
ATI RN Clinical Judgment Comprehensive Review | Nursing Process &
Prioritization Practice Test | Cue Recognition, Analysis & Hypothesis Generation
| Safe Patient Care, Clinical Reasoning & Decision-Making Study Guide | NCLEX-
RN NGN Preparation Resource | Updated Practice Assessment with Detailed
Answer Explanations | Comprehensive Nursing Clinical Judgment Review for
Exam Success
Cardiovascular & Respiratory
Question 1
A nurse is assessing a client with heart failure. Which finding indicates worsening
fluid overload?
A. Weight loss of 1 lb in 24 hours
B. Jugular venous distention
C. Dry, hacking cough
D. Blood pressure 110/70 mmHg
Answer: B. Jugular venous distention
Rationale:
• A. Weight loss of 1 lb in 24 hours: This indicates improvement, not
worsening. Weight gain (2-3 lbs in 24 hours) would indicate fluid overload.
• B. Jugular venous distention: CORRECT. JVD is a hallmark sign of right-sided
heart failure and worsening fluid volume overload, indicating increased
central venous pressure.
• C. Dry, hacking cough: This is more associated with ACE inhibitor use
(angioedema) or early pulmonary congestion, but JVD is a more direct
indicator of fluid overload.
• D. Blood pressure 110/70 mmHg: This is a normal blood pressure and does
not indicate worsening fluid status.
,Question 2
A client with pneumonia has a SpO2 of 89% on room air. What is the nurse's
priority action?
A. Apply oxygen at 2 L/min via nasal cannula
B. Encourage deep breathing and coughing
C. Notify the provider immediately
D. Position the client in high-Fowler's position
Answer: A. Apply oxygen at 2 L/min via nasal cannula
Rationale:
• A. Apply oxygen at 2 L/min via nasal cannula: CORRECT. The priority is to
correct hypoxemia. Oxygen administration is the immediate intervention
for a low SpO2.
• B. Encourage deep breathing and coughing: This is important but not the
priority. The client needs supplemental oxygen first to correct the hypoxia.
• C. Notify the provider immediately: While the provider should be notified,
the nurse must first intervene to improve oxygenation.
• D. Position the client in high-Fowler's position: This is helpful to improve
lung expansion but is not the priority over oxygen administration.
Question 3
A nurse is caring for a client 2 hours after a cardiac catheterization via the femoral
artery. Which finding requires immediate action?
A. Hematoma at the insertion site
B. Pedal pulses palpable bilaterally
C. Client reports mild back pain
D. Blood pressure 118/76 mmHg
Answer: A. Hematoma at the insertion site
Rationale:
, • A. Hematoma at the insertion site: CORRECT. A growing hematoma
indicates bleeding at the puncture site and can lead to significant blood loss
or pseudoaneurysm. This requires immediate intervention.
• B. Pedal pulses palpable bilaterally: This is an expected finding indicating
good perfusion.
• C. Client reports mild back pain: This is common after lying flat and is not
immediately concerning.
• D. Blood pressure 118/76 mmHg: This is a stable blood pressure.
Question 4
A client is prescribed digoxin for heart failure. Which finding indicates digoxin
toxicity?
A. Heart rate 62 bpm
B. Anorexia and nausea
C. Blood pressure 120/80 mmHg
D. Urine output 50 mL/hr
Answer: B. Anorexia and nausea
Rationale:
• A. Heart rate 62 bpm: This is a normal heart rate. Bradycardia (HR < 60) is a
sign of digoxin toxicity, but this rate is not concerning.
• B. Anorexia and nausea: CORRECT. Gastrointestinal symptoms (nausea,
vomiting, anorexia) are early signs of digoxin toxicity, along with visual
disturbances (yellow-green halos) and cardiac dysrhythmias.
• C. Blood pressure 120/80 mmHg: This is normal.
• D. Urine output 50 mL/hr: This is adequate urine output.
Question 5
A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The nurse is
concerned about which complication?
, A. Oxygen toxicity
B. Suppression of hypoxic drive
C. Carbon dioxide retention
D. Nasal mucosal drying
Answer: B. Suppression of hypoxic drive
Rationale:
• A. Oxygen toxicity: This is a concern with high concentrations of oxygen
over long periods, but the rate of 4 L/min is not typically toxic.
• B. Suppression of hypoxic drive: CORRECT. Clients with COPD may rely on
hypoxic drive to stimulate breathing. High-flow oxygen can suppress this
drive, leading to hypoventilation and respiratory acidosis. Oxygen should be
titrated to maintain SpO2 of 88-92%.
• C. Carbon dioxide retention: This is the result of suppressing the hypoxic
drive, not the direct complication.
• D. Nasal mucosal drying: This is a minor side effect, not the primary
concern.
Question 6
A nurse is assessing a client with pericarditis. Which finding is characteristic?
A. Pain relieved by lying flat
B. Friction rub heard at the left sternal border
C. Pain worsened by sitting forward
D. Bradycardia
Answer: B. Friction rub heard at the left sternal border
Rationale:
• A. Pain relieved by lying flat: This is incorrect. Pericardial pain is worsened
by lying flat and relieved by sitting forward (leaning forward).
• B. Friction rub heard at the left sternal border: CORRECT. A pericardial
friction rub is a classic finding in pericarditis, heard best at the left lower
sternal border with the client leaning forward.
