ATI RN CONCEPT LEVEL 3 EXAMINATION COMPLETE
QUESTIONS AND DETAILED SOLUTIONS LATEST UPDATE
THIS YEAR JUST RELEASED
A nurse receives report on four clients at the beginning of a shift. Which
client should the nurse assess first based on priority and immediate risk?
A. A client with heart failure who has 2+ bilateral ankle edema
B. A client with pneumonia whose oxygen saturation is 86% on 2 L/min nasal
cannula
C. A postoperative client requesting medication for incisional pain rated
7/10
D. A client with diabetes whose blood glucose is 198 mg/dL before breakfast
Answer: B
Rationale: An oxygen saturation of 86% despite supplemental oxygen
indicates impaired oxygenation and requires immediate assessment and
intervention. Airway and breathing take priority over pain, chronic edema,
or moderate hyperglycemia.
2.
A nurse is caring for a client who suddenly becomes confused, restless, and
diaphoretic. Which action should the nurse take first?
A. Obtain a complete neurological history
B. Administer prescribed antianxiety medication
C. Check the client's blood glucose level
D. Ask the family whether confusion is baseline
,Answer: C
Rationale: Sudden confusion, restlessness, and diaphoresis can indicate
hypoglycemia. Checking blood glucose rapidly identifies a potentially
reversible and life-threatening cause.
3.
A client receiving an opioid analgesic becomes difficult to arouse and has a
respiratory rate of 7/min. Which intervention has the highest priority?
A. Place the client in a supine position
B. Administer naloxone as prescribed
C. Encourage the client to drink fluids
D. Document the client's sedation level
Answer: B
Rationale: Severe respiratory depression following opioid administration
requires immediate reversal with naloxone while supporting airway and
breathing.
4.
A nurse discovers that a client has fallen while attempting to ambulate
independently. Which action should the nurse take first?
A. Complete an incident report
B. Notify the client's family
C. Assess the client for injury
D. Document the fall in the medical record
Answer: C
,Rationale: The nurse must first assess the client for injury and stabilize the
client. Documentation and notification occur after immediate assessment
and interventions.
5.
A client with dysphagia following a stroke is prescribed oral medications.
Which intervention is most appropriate?
A. Administer medications while the client is lying flat
B. Crush every medication before administration
C. Verify which medications can safely be crushed
D. Give all medications with a large glass of water
Answer: C
Rationale: Some medications, including extended-release and enteric-
coated formulations, must not be crushed. The nurse should evaluate each
medication individually and follow swallowing precautions.
6.
A nurse is preparing to administer medication through a feeding tube.
Which action is appropriate?
A. Mix all medications together before administration
B. Flush the tube before and between medications
C. Add medications directly to the enteral formula
D. Stop all enteral nutrition for 24 hours
Answer: B
, Rationale: Flushing before and between medications helps maintain tube
patency and prevents medication incompatibilities.
7.
A hospitalized client becomes increasingly agitated and attempts to remove
an IV catheter. Which intervention should the nurse implement first?
A. Apply bilateral wrist restraints
B. Request a sedative prescription
C. Identify and address the underlying cause
D. Ask security personnel to remain with the client
Answer: C
Rationale: Agitation can result from hypoxia, pain, infection, medication
effects, or delirium. The least restrictive approach is to identify and treat the
underlying cause before restraints or sedation.
8.
A nurse is caring for a client with suspected tuberculosis. Which personal
protective equipment is required when entering the room?
A. Surgical mask
B. N95 respirator
C. Sterile gloves only
D. Face shield only
Answer: B
Rationale: Tuberculosis requires airborne precautions. Healthcare personnel
should use an appropriately fitted N95 or equivalent respirator.
QUESTIONS AND DETAILED SOLUTIONS LATEST UPDATE
THIS YEAR JUST RELEASED
A nurse receives report on four clients at the beginning of a shift. Which
client should the nurse assess first based on priority and immediate risk?
A. A client with heart failure who has 2+ bilateral ankle edema
B. A client with pneumonia whose oxygen saturation is 86% on 2 L/min nasal
cannula
C. A postoperative client requesting medication for incisional pain rated
7/10
D. A client with diabetes whose blood glucose is 198 mg/dL before breakfast
Answer: B
Rationale: An oxygen saturation of 86% despite supplemental oxygen
indicates impaired oxygenation and requires immediate assessment and
intervention. Airway and breathing take priority over pain, chronic edema,
or moderate hyperglycemia.
2.
A nurse is caring for a client who suddenly becomes confused, restless, and
diaphoretic. Which action should the nurse take first?
A. Obtain a complete neurological history
B. Administer prescribed antianxiety medication
C. Check the client's blood glucose level
D. Ask the family whether confusion is baseline
,Answer: C
Rationale: Sudden confusion, restlessness, and diaphoresis can indicate
hypoglycemia. Checking blood glucose rapidly identifies a potentially
reversible and life-threatening cause.
3.
A client receiving an opioid analgesic becomes difficult to arouse and has a
respiratory rate of 7/min. Which intervention has the highest priority?
A. Place the client in a supine position
B. Administer naloxone as prescribed
C. Encourage the client to drink fluids
D. Document the client's sedation level
Answer: B
Rationale: Severe respiratory depression following opioid administration
requires immediate reversal with naloxone while supporting airway and
breathing.
4.
A nurse discovers that a client has fallen while attempting to ambulate
independently. Which action should the nurse take first?
A. Complete an incident report
B. Notify the client's family
C. Assess the client for injury
D. Document the fall in the medical record
Answer: C
,Rationale: The nurse must first assess the client for injury and stabilize the
client. Documentation and notification occur after immediate assessment
and interventions.
5.
A client with dysphagia following a stroke is prescribed oral medications.
Which intervention is most appropriate?
A. Administer medications while the client is lying flat
B. Crush every medication before administration
C. Verify which medications can safely be crushed
D. Give all medications with a large glass of water
Answer: C
Rationale: Some medications, including extended-release and enteric-
coated formulations, must not be crushed. The nurse should evaluate each
medication individually and follow swallowing precautions.
6.
A nurse is preparing to administer medication through a feeding tube.
Which action is appropriate?
A. Mix all medications together before administration
B. Flush the tube before and between medications
C. Add medications directly to the enteral formula
D. Stop all enteral nutrition for 24 hours
Answer: B
, Rationale: Flushing before and between medications helps maintain tube
patency and prevents medication incompatibilities.
7.
A hospitalized client becomes increasingly agitated and attempts to remove
an IV catheter. Which intervention should the nurse implement first?
A. Apply bilateral wrist restraints
B. Request a sedative prescription
C. Identify and address the underlying cause
D. Ask security personnel to remain with the client
Answer: C
Rationale: Agitation can result from hypoxia, pain, infection, medication
effects, or delirium. The least restrictive approach is to identify and treat the
underlying cause before restraints or sedation.
8.
A nurse is caring for a client with suspected tuberculosis. Which personal
protective equipment is required when entering the room?
A. Surgical mask
B. N95 respirator
C. Sterile gloves only
D. Face shield only
Answer: B
Rationale: Tuberculosis requires airborne precautions. Healthcare personnel
should use an appropriately fitted N95 or equivalent respirator.
