ATI
NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
,ATI MED-SURG MIDTERM EXAM PREPARATION (2026) | NGN CLINICAL JUDGMENT
QUESTIONS AND ANSWERS WITH RATIONALES
DOMAIN 1: PRIORITY SETTING & CLINICAL JUDGMENT
Question 1
The nurse receives report on four patients. Using the ABC (Airway-Breathing-Circulation)
framework, which patient should the nurse assess first?
A) A patient with active gastrointestinal bleeding and a heart rate of 110/min
B) A patient reporting severe postoperative pain rated 8/10
C) A patient with a suspected airway obstruction who is clutching their throat and unable to
speak
D) A patient with a new onset of confusion following a fall
Correct Answer: C
Rationale: According to the ABC framework, airway is the highest priority. A patient with a
suspected airway obstruction who cannot speak requires immediate life-saving intervention.
While bleeding (circulation), pain, and confusion are important, a compromised airway takes
precedence as it can lead to death within minutes.
Question 2
A nurse is prioritizing care for four patients using Maslow's hierarchy of needs. Which patient
need should the nurse address first?
A) A patient who is expressing anxiety about an upcoming procedure
B) A patient who requests to speak with a chaplain for spiritual support
C) A patient who expresses feelings of low self-esteem after a new diagnosis
D) A patient with a blood pressure of 84/50 mmHg who appears pale and diaphoretic
,Correct Answer: D
Rationale: According to Maslow's hierarchy, physiological needs take the highest priority. A
blood pressure of 84/50 mmHg with signs of shock (pale, diaphoretic) represents an immediate
physiological threat to life. Safety needs come next, followed by love/belonging, esteem, and
self-actualization.
Question 3
A nurse delegates vital signs to a nursing assistant. Which action is most important for the
nurse to take regarding delegation?
A) Document the delegation in the chart
B) Verify that the UAP has been trained to perform the task
C) Ask the UAP to report only abnormal findings
D) Delegate all vital signs for the shift at once
Correct Answer: B
Rationale: The nurse must verify the delegate's competency and training before delegating a
task. The nurse retains accountability for the delegated task and must ensure the UAP has the
appropriate knowledge and skills. Delegation should match the delegate's scope of practice.
DOMAIN 2: CARDIOVASCULAR DISORDERS
Question 4
A nurse is assessing a client with right-sided heart failure. Which finding should the nurse
expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
, C) Jugular venous distension (JVD)
D) Frothy sputum
Correct Answer: C
Rationale: Right-sided heart failure causes systemic venous backup leading to JVD, peripheral
edema, and hepatomegaly. Crackles, PND, and frothy sputum indicate left-sided heart failure,
which causes pulmonary congestion.
Question 5
A client with heart failure on digoxin reports nausea and yellow-tinged vision. What is the
nurse's priority action?
A) Administer digoxin immune Fab
B) Check the digoxin level
C) Give the next dose as ordered
D) Encourage oral fluids
Correct Answer: B
Rationale: Nausea, vomiting, and yellow vision (xanthopsia) are classic signs of digoxin toxicity.
The nurse should check the digoxin level first before notifying the provider. Digoxin immune
Fab is administered for severe toxicity after confirmation.
Question 6
A client receiving IV heparin has an aPTT of 110 seconds (control 30 seconds). What should the
nurse do?
A) Continue the infusion
B) Increase the rate
NURSING
QUESTIONS & ANSWERS WITH
RATIONALES
,ATI MED-SURG MIDTERM EXAM PREPARATION (2026) | NGN CLINICAL JUDGMENT
QUESTIONS AND ANSWERS WITH RATIONALES
DOMAIN 1: PRIORITY SETTING & CLINICAL JUDGMENT
Question 1
The nurse receives report on four patients. Using the ABC (Airway-Breathing-Circulation)
framework, which patient should the nurse assess first?
A) A patient with active gastrointestinal bleeding and a heart rate of 110/min
B) A patient reporting severe postoperative pain rated 8/10
C) A patient with a suspected airway obstruction who is clutching their throat and unable to
speak
D) A patient with a new onset of confusion following a fall
Correct Answer: C
Rationale: According to the ABC framework, airway is the highest priority. A patient with a
suspected airway obstruction who cannot speak requires immediate life-saving intervention.
While bleeding (circulation), pain, and confusion are important, a compromised airway takes
precedence as it can lead to death within minutes.
Question 2
A nurse is prioritizing care for four patients using Maslow's hierarchy of needs. Which patient
need should the nurse address first?
A) A patient who is expressing anxiety about an upcoming procedure
B) A patient who requests to speak with a chaplain for spiritual support
C) A patient who expresses feelings of low self-esteem after a new diagnosis
D) A patient with a blood pressure of 84/50 mmHg who appears pale and diaphoretic
,Correct Answer: D
Rationale: According to Maslow's hierarchy, physiological needs take the highest priority. A
blood pressure of 84/50 mmHg with signs of shock (pale, diaphoretic) represents an immediate
physiological threat to life. Safety needs come next, followed by love/belonging, esteem, and
self-actualization.
Question 3
A nurse delegates vital signs to a nursing assistant. Which action is most important for the
nurse to take regarding delegation?
A) Document the delegation in the chart
B) Verify that the UAP has been trained to perform the task
C) Ask the UAP to report only abnormal findings
D) Delegate all vital signs for the shift at once
Correct Answer: B
Rationale: The nurse must verify the delegate's competency and training before delegating a
task. The nurse retains accountability for the delegated task and must ensure the UAP has the
appropriate knowledge and skills. Delegation should match the delegate's scope of practice.
DOMAIN 2: CARDIOVASCULAR DISORDERS
Question 4
A nurse is assessing a client with right-sided heart failure. Which finding should the nurse
expect?
A) Crackles in the lung bases
B) Paroxysmal nocturnal dyspnea
, C) Jugular venous distension (JVD)
D) Frothy sputum
Correct Answer: C
Rationale: Right-sided heart failure causes systemic venous backup leading to JVD, peripheral
edema, and hepatomegaly. Crackles, PND, and frothy sputum indicate left-sided heart failure,
which causes pulmonary congestion.
Question 5
A client with heart failure on digoxin reports nausea and yellow-tinged vision. What is the
nurse's priority action?
A) Administer digoxin immune Fab
B) Check the digoxin level
C) Give the next dose as ordered
D) Encourage oral fluids
Correct Answer: B
Rationale: Nausea, vomiting, and yellow vision (xanthopsia) are classic signs of digoxin toxicity.
The nurse should check the digoxin level first before notifying the provider. Digoxin immune
Fab is administered for severe toxicity after confirmation.
Question 6
A client receiving IV heparin has an aPTT of 110 seconds (control 30 seconds). What should the
nurse do?
A) Continue the infusion
B) Increase the rate
