ATI RN Comprehensive Practice Assessment A 2026–2027 |
Latest Version | Complete Study Guide | Practice Questions
with Detailed Rationales | Comprehensive NCLEX-RN Review |
Fundamentals, Medical-Surgical, Pharmacology, Maternal-
Newborn, Pediatrics, Mental Health, Leadership, Community
Health, Nutrition & NGN Clinical Judgment Exam Preparation
MEDICAL-SURGICAL NURSING
Question 1
A home health nurse is evaluating a school-age child who has cystic fibrosis. The
nurse should initiate a request for a high-frequency chest compression vest in
response to which of the following parent statements?
A. "My child doesn't like to sit still for nebulizer treatments."
B. "I think that my child has been running a fever over the last couple of days."
C. "My child has only a small amount of mucus after percussion therapy."
D. "I am concerned about my child's future participation in team sports."
Correct Answer: C
Rationale: The high-frequency chest compression vest is indicated when chest
percussion therapy is ineffective. The parent's statement that the child has only a
small amount of mucus after percussion therapy suggests the current therapy is
not adequately clearing secretions, indicating the need for a more effective
intervention. Fever and sports participation are not indications for this device .
Question 2
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe
ankle pain after falling off a stepstool at home. Which of the following
prescriptions should the nurse clarify with the provider?
A. Obtain capillary blood glucose level every 2 hr.
B. Check the neurovascular status of the client's lower extremities every hour.
,C. Apply a cold pack to the client's ankle for 30 min every hour.
D. Maintain the affected ankle elevated and immobilized.
Correct Answer: C
Rationale: Cold packs should typically be applied for 15-20 minutes at a time, not
30 minutes every hour. Prolonged cold application can cause tissue damage,
including vasoconstriction that may compromise perfusion, especially in a client
with diabetes who may have peripheral vascular impairment. The other orders
are appropriate for managing a potential ankle injury .
Question 3
A nurse is assessing a newborn who is 2 hr old. Which of the following findings
should the nurse report to the provider?
A. Slightly blue hands and feet
B. Respiratory rate 40/min
C. Axillary temperature 36.2°C (97.2°F)
D. Apical pulse 136/min
Correct Answer: C
Rationale: The expected axillary temperature for a newborn is 36.5°C to 37.5°C
(97.7°F to 99.5°F). A temperature of 36.2°C (97.2°F) is below the expected
reference range and indicates hypothermia, which should be reported.
Acrocyanosis (slightly blue hands and feet) is normal in the first 24 hours. A
respiratory rate of 40/min is within the expected range of 30-60/min. An apical
pulse of 136/min is within the expected range of 110-160/min .
Question 4
A nurse is planning care for a client who has a deficit with cranial nerve (CN) II.
Which of the following actions should the nurse plan to take?
A. Keep the client resting in bed.
B. Ask the client to restate directions.
,C. Clear objects from the client's walking area.
D. Evaluate the client's ability to swallow.
Correct Answer: C
Rationale: Cranial nerve II is the optic nerve, responsible for vision. A deficit in CN
II would result in visual impairment. The nurse should clear objects from the
client's walking area to prevent falls and injury. Asking the client to restate
directions and evaluating swallowing relate to other cranial nerves (CN VIII and
CN IX/X respectively) .
Question 5
A nurse is caring for a client who is receiving a transfusion of packed red blood
cells (RBCs). The nurse should suspect a transfusion reaction based on which of
the following assessment findings? (Select all that apply)
A. Back pain
B. Anxiety
C. Headache
D. Hypertension
E. Flushed face
Correct Answers: A, B, C
Rationale: Signs of a hemolytic transfusion reaction include back pain, anxiety,
headache, chills, fever, tachycardia, hypotension (not hypertension), and chest
tightness. Back pain is a classic sign caused by hemolysis. Flushed face is not
typically associated with transfusion reactions .
Question 6
A nurse is assessing a client who has macular degeneration. Which of the
following findings should the nurse expect?
A. Increased intraocular pressure
B. Floating dark spots
, C. Decreased central vision
D. Double vision
Correct Answer: C
Rationale: Macular degeneration affects the macula, the central part of the retina
responsible for sharp, central vision. Clients with macular degeneration
experience decreased or loss of central vision while peripheral vision remains
intact. Increased intraocular pressure is associated with glaucoma. Floating dark
spots are associated with retinal detachment. Double vision is associated with
cataracts or cranial nerve dysfunction .
Question 7
A nurse is creating a plan of care for a client who has left-sided weakness
following a stroke. Which of the following interventions should the nurse include
in the plan?
A. Massage bony prominences on the client's left side
B. Support the client's left arm on a pillow while sitting
C. Position the bedside table on the client's left side
D. Place the client's cane on their left side while ambulating
Correct Answer: B
Rationale: Supporting the affected (left) arm on a pillow while sitting prevents
shoulder subluxation and promotes proper alignment. Massaging bony
prominences can cause skin breakdown. The bedside table should be on the
unaffected (right) side for the client to easily access items. The cane should be
held on the unaffected (right) side when ambulating .
Question 8
A nurse is preparing to administer a long-acting insulin to a client who has
diabetes mellitus. Which of the following actions should the nurse plan to take
first?
Latest Version | Complete Study Guide | Practice Questions
with Detailed Rationales | Comprehensive NCLEX-RN Review |
Fundamentals, Medical-Surgical, Pharmacology, Maternal-
Newborn, Pediatrics, Mental Health, Leadership, Community
Health, Nutrition & NGN Clinical Judgment Exam Preparation
MEDICAL-SURGICAL NURSING
Question 1
A home health nurse is evaluating a school-age child who has cystic fibrosis. The
nurse should initiate a request for a high-frequency chest compression vest in
response to which of the following parent statements?
A. "My child doesn't like to sit still for nebulizer treatments."
B. "I think that my child has been running a fever over the last couple of days."
C. "My child has only a small amount of mucus after percussion therapy."
D. "I am concerned about my child's future participation in team sports."
Correct Answer: C
Rationale: The high-frequency chest compression vest is indicated when chest
percussion therapy is ineffective. The parent's statement that the child has only a
small amount of mucus after percussion therapy suggests the current therapy is
not adequately clearing secretions, indicating the need for a more effective
intervention. Fever and sports participation are not indications for this device .
Question 2
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe
ankle pain after falling off a stepstool at home. Which of the following
prescriptions should the nurse clarify with the provider?
A. Obtain capillary blood glucose level every 2 hr.
B. Check the neurovascular status of the client's lower extremities every hour.
,C. Apply a cold pack to the client's ankle for 30 min every hour.
D. Maintain the affected ankle elevated and immobilized.
Correct Answer: C
Rationale: Cold packs should typically be applied for 15-20 minutes at a time, not
30 minutes every hour. Prolonged cold application can cause tissue damage,
including vasoconstriction that may compromise perfusion, especially in a client
with diabetes who may have peripheral vascular impairment. The other orders
are appropriate for managing a potential ankle injury .
Question 3
A nurse is assessing a newborn who is 2 hr old. Which of the following findings
should the nurse report to the provider?
A. Slightly blue hands and feet
B. Respiratory rate 40/min
C. Axillary temperature 36.2°C (97.2°F)
D. Apical pulse 136/min
Correct Answer: C
Rationale: The expected axillary temperature for a newborn is 36.5°C to 37.5°C
(97.7°F to 99.5°F). A temperature of 36.2°C (97.2°F) is below the expected
reference range and indicates hypothermia, which should be reported.
Acrocyanosis (slightly blue hands and feet) is normal in the first 24 hours. A
respiratory rate of 40/min is within the expected range of 30-60/min. An apical
pulse of 136/min is within the expected range of 110-160/min .
Question 4
A nurse is planning care for a client who has a deficit with cranial nerve (CN) II.
Which of the following actions should the nurse plan to take?
A. Keep the client resting in bed.
B. Ask the client to restate directions.
,C. Clear objects from the client's walking area.
D. Evaluate the client's ability to swallow.
Correct Answer: C
Rationale: Cranial nerve II is the optic nerve, responsible for vision. A deficit in CN
II would result in visual impairment. The nurse should clear objects from the
client's walking area to prevent falls and injury. Asking the client to restate
directions and evaluating swallowing relate to other cranial nerves (CN VIII and
CN IX/X respectively) .
Question 5
A nurse is caring for a client who is receiving a transfusion of packed red blood
cells (RBCs). The nurse should suspect a transfusion reaction based on which of
the following assessment findings? (Select all that apply)
A. Back pain
B. Anxiety
C. Headache
D. Hypertension
E. Flushed face
Correct Answers: A, B, C
Rationale: Signs of a hemolytic transfusion reaction include back pain, anxiety,
headache, chills, fever, tachycardia, hypotension (not hypertension), and chest
tightness. Back pain is a classic sign caused by hemolysis. Flushed face is not
typically associated with transfusion reactions .
Question 6
A nurse is assessing a client who has macular degeneration. Which of the
following findings should the nurse expect?
A. Increased intraocular pressure
B. Floating dark spots
, C. Decreased central vision
D. Double vision
Correct Answer: C
Rationale: Macular degeneration affects the macula, the central part of the retina
responsible for sharp, central vision. Clients with macular degeneration
experience decreased or loss of central vision while peripheral vision remains
intact. Increased intraocular pressure is associated with glaucoma. Floating dark
spots are associated with retinal detachment. Double vision is associated with
cataracts or cranial nerve dysfunction .
Question 7
A nurse is creating a plan of care for a client who has left-sided weakness
following a stroke. Which of the following interventions should the nurse include
in the plan?
A. Massage bony prominences on the client's left side
B. Support the client's left arm on a pillow while sitting
C. Position the bedside table on the client's left side
D. Place the client's cane on their left side while ambulating
Correct Answer: B
Rationale: Supporting the affected (left) arm on a pillow while sitting prevents
shoulder subluxation and promotes proper alignment. Massaging bony
prominences can cause skin breakdown. The bedside table should be on the
unaffected (right) side for the client to easily access items. The cane should be
held on the unaffected (right) side when ambulating .
Question 8
A nurse is preparing to administer a long-acting insulin to a client who has
diabetes mellitus. Which of the following actions should the nurse plan to take
first?
