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ATI Next Generation NCLEX Clinical Judgment Practice Exam
Preparation With Complete Questions And Correct Answers With
Rationales Already Graded A+ Brand New Version!!
Question 1
A nurse is caring for a client who has a new diagnosis of type 1 diabetes
mellitus. Which of the following findings indicates a need for immediate
intervention?
A. Blood glucose level of 180 mg/dL
B. Serum potassium level of 3.2 mEq/L
C. Urine output of 60 mL in the past 2 hours
D. Respiratory rate of 22 breaths per minute
Answer: B. Serum potassium level of 3.2 mEq/L
Explanation: A serum potassium of 3.2 mEq/L is below the normal range
of 3.5 to 5.0 mEq/L and indicates hypokalemia, which can lead to life-
threatening cardiac dysrhythmias. While hyperglycemia and polyuria
are expected in diabetes, hypokalemia requires urgent correction,
especially if insulin therapy is initiated, as insulin drives potassium into
cells, worsening hypokalemia. Urine output of 60 mL over 2 hours (30
mL/hr) is adequate, and a respiratory rate of 22 is within normal limits.
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Question 2
A nurse is assessing a client who is postoperative day 1 following
abdominal surgery. Which of the following findings is the earliest
indicator of hypovolemic shock?
A. Decreased blood pressure
B. Tachycardia
C. Oliguria
D. Cool, clammy skin
Answer: B. Tachycardia
Explanation: Tachycardia is an early compensatory response to
decreased circulating blood volume as the sympathetic nervous system
activates to maintain cardiac output. Blood pressure may remain
normal initially due to vasoconstriction, making it a later sign. Oliguria
and cool, clammy skin occur as shock progresses.
Question 3
A client with heart failure is prescribed furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
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Answer: B. Serum potassium
Explanation: Furosemide is a loop diuretic that inhibits sodium and
chloride reabsorption in the ascending loop of Henle, leading to
increased potassium excretion. Hypokalemia can precipitate digoxin
toxicity if the client is on digoxin and increase the risk of cardiac
arrhythmias. While sodium, calcium, and magnesium may be affected,
potassium is the most critical due to its direct impact on cardiac
function.
Question 4
A nurse is preparing to administer heparin subcutaneously to a client
with deep vein thrombosis. Which of the following actions is correct?
A. Massage the site after injection
B. Use a 22-gauge needle
C. Administer in the abdomen
D. Aspirate before injection
Answer: C. Administer in the abdomen
Explanation: Heparin is administered subcutaneously in the abdominal
fatty tissue, at least 2 inches from the umbilicus, to ensure consistent
absorption. The site should not be massaged to avoid bruising or
hematoma formation. A small-gauge needle (25–26 gauge) is used, and
aspiration is not recommended because it can damage tissue and cause
bleeding.
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Question 5
A client is receiving morphine sulfate for severe pain. Which of the
following assessments is the priority?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Level of consciousness
Answer: B. Respiratory rate
Explanation: Morphine is a potent opioid that can cause respiratory
depression by decreasing the sensitivity of the respiratory center to
carbon dioxide. Respiratory rate is the priority assessment because
respiratory depression is the most life-threatening adverse effect. While
pain level, blood pressure, and sedation are important, they are
secondary to maintaining adequate ventilation.
Question 6
A nurse is educating a client about dietary management of chronic
kidney disease. Which food should the client avoid?
A. Apples
B. Bananas
C. Cabbage
D. Grapes
ATI Next Generation NCLEX Clinical Judgment Practice Exam
Preparation With Complete Questions And Correct Answers With
Rationales Already Graded A+ Brand New Version!!
Question 1
A nurse is caring for a client who has a new diagnosis of type 1 diabetes
mellitus. Which of the following findings indicates a need for immediate
intervention?
A. Blood glucose level of 180 mg/dL
B. Serum potassium level of 3.2 mEq/L
C. Urine output of 60 mL in the past 2 hours
D. Respiratory rate of 22 breaths per minute
Answer: B. Serum potassium level of 3.2 mEq/L
Explanation: A serum potassium of 3.2 mEq/L is below the normal range
of 3.5 to 5.0 mEq/L and indicates hypokalemia, which can lead to life-
threatening cardiac dysrhythmias. While hyperglycemia and polyuria
are expected in diabetes, hypokalemia requires urgent correction,
especially if insulin therapy is initiated, as insulin drives potassium into
cells, worsening hypokalemia. Urine output of 60 mL over 2 hours (30
mL/hr) is adequate, and a respiratory rate of 22 is within normal limits.
,2|Page
Question 2
A nurse is assessing a client who is postoperative day 1 following
abdominal surgery. Which of the following findings is the earliest
indicator of hypovolemic shock?
A. Decreased blood pressure
B. Tachycardia
C. Oliguria
D. Cool, clammy skin
Answer: B. Tachycardia
Explanation: Tachycardia is an early compensatory response to
decreased circulating blood volume as the sympathetic nervous system
activates to maintain cardiac output. Blood pressure may remain
normal initially due to vasoconstriction, making it a later sign. Oliguria
and cool, clammy skin occur as shock progresses.
Question 3
A client with heart failure is prescribed furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
,3|Page
Answer: B. Serum potassium
Explanation: Furosemide is a loop diuretic that inhibits sodium and
chloride reabsorption in the ascending loop of Henle, leading to
increased potassium excretion. Hypokalemia can precipitate digoxin
toxicity if the client is on digoxin and increase the risk of cardiac
arrhythmias. While sodium, calcium, and magnesium may be affected,
potassium is the most critical due to its direct impact on cardiac
function.
Question 4
A nurse is preparing to administer heparin subcutaneously to a client
with deep vein thrombosis. Which of the following actions is correct?
A. Massage the site after injection
B. Use a 22-gauge needle
C. Administer in the abdomen
D. Aspirate before injection
Answer: C. Administer in the abdomen
Explanation: Heparin is administered subcutaneously in the abdominal
fatty tissue, at least 2 inches from the umbilicus, to ensure consistent
absorption. The site should not be massaged to avoid bruising or
hematoma formation. A small-gauge needle (25–26 gauge) is used, and
aspiration is not recommended because it can damage tissue and cause
bleeding.
, 4|Page
Question 5
A client is receiving morphine sulfate for severe pain. Which of the
following assessments is the priority?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Level of consciousness
Answer: B. Respiratory rate
Explanation: Morphine is a potent opioid that can cause respiratory
depression by decreasing the sensitivity of the respiratory center to
carbon dioxide. Respiratory rate is the priority assessment because
respiratory depression is the most life-threatening adverse effect. While
pain level, blood pressure, and sedation are important, they are
secondary to maintaining adequate ventilation.
Question 6
A nurse is educating a client about dietary management of chronic
kidney disease. Which food should the client avoid?
A. Apples
B. Bananas
C. Cabbage
D. Grapes
