ATI Fundamentals | NGN Exam 9 Study Guide Clinical
Judgment Practice Q&A + Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse is assessing a client who is 24 hours postoperative. Which of the
following findings should the nurse identify as a priority?
A. Client reports pain as 7 on a scale of 0 to 10.
B. Client has not yet ambulated in the hallway.
C. Urine output is 20 mL/hr for the past 2 hours.
D. Incisional serosanguineous drainage is noted on the dressing.
Answer: C
Rationale: Urine output less than 30 mL/hr can indicate decreased renal perfusion or
hypovolemia and is the highest priority for intervention compared to pain or expected
postoperative findings.
2. A nurse is preparing to provide care for a client who has Clostridioides
difficile. Which of the following precautions should the nurse take?
A. Wear a mask and goggles during all client interactions.
B. Place the client in a private room with contact precautions.
C. Perform hand hygiene with an alcohol-based hand rub.
D. Keep the client’s door closed at all times.
Answer: B
Rationale: C. diff requires contact precautions, which include a private room and the use of
gloves and gowns. Hand hygiene must be performed with soap and water because alcohol-
based rubs are ineffective against C. diff spores.
,3. A nurse is educating a newly licensed nurse about the ‘Recognize Cues’ step
of the Clinical Judgment Measurement Model. Which of the following actions
should the nurse include?
A. Identifying relevant data from a client’s medical record.
B. Formulating a nursing diagnosis based on data.
C. Predicting potential complications for the client.
D. Deciding which intervention to implement first.
Answer: A
Rationale: Recognizing cues is the first step of the CJMM and involves identifying
significant data (signs, symptoms, lab values) from various sources.
4. A nurse is caring for a client who is falling. Which of the following actions
should the nurse take?
A. Hold the client upright to prevent them from hitting the floor.
B. Grab the client under the arms and pull them toward a chair.
C. Extend one leg and allow the client to slide down it to the floor.
D. Call for help and wait for assistance before moving the client.
Answer: C
Rationale: If a client begins to fall, the nurse should create a wide base of support, extend
one leg, and allow the client to slide down the leg to the floor to minimize injury for both.
5. Which of the following is the priority action when using the RACE acronym for
fire safety?
A. Activate the fire alarm system.
B. Confine the fire by closing doors and windows.
C. Extinguish the fire using a portable extinguisher.
D. Rescue and move clients to a safe area.
Answer: D
, Rationale: In the RACE acronym (Rescue, Alarm, Confine, Extinguish), the priority is
always to rescue and protect clients in immediate danger.
6. A nurse is assessing a client’s radial pulse and notes it is irregular. Which of
the following actions should the nurse take?
A. Wait 10 minutes and reassess the radial pulse.
B. Assess the apical pulse for one full minute.
C. Document the pulse as ‘normal for the client.’
D. Request a stat electrocardiogram (ECG).
Answer: B
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain an accurate heart rate and rhythm.
7. A nurse is preparing to administer an intramuscular (IM) injection. Which of
the following is the preferred site for a large volume injection in an adult?
A. Ventrogluteal
B. Dorsogluteal
C. Deltoid
D. Vastus lateralis
Answer: A
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is deep and away from major blood vessels and nerves.
8. A client who is non-verbal appears restless and is grimacing. Which of the
following pain scales should the nurse use?
A. Numerical Rating Scale (0-10)
B. Wong-Baker FACES Scale
C. FLACC Scale
D. Visual Analog Scale
Answer: C
Judgment Practice Q&A + Rationales UPDATED ACTUAL
Questions and CORRECT Answers
1. A nurse is assessing a client who is 24 hours postoperative. Which of the
following findings should the nurse identify as a priority?
A. Client reports pain as 7 on a scale of 0 to 10.
B. Client has not yet ambulated in the hallway.
C. Urine output is 20 mL/hr for the past 2 hours.
D. Incisional serosanguineous drainage is noted on the dressing.
Answer: C
Rationale: Urine output less than 30 mL/hr can indicate decreased renal perfusion or
hypovolemia and is the highest priority for intervention compared to pain or expected
postoperative findings.
2. A nurse is preparing to provide care for a client who has Clostridioides
difficile. Which of the following precautions should the nurse take?
A. Wear a mask and goggles during all client interactions.
B. Place the client in a private room with contact precautions.
C. Perform hand hygiene with an alcohol-based hand rub.
D. Keep the client’s door closed at all times.
Answer: B
Rationale: C. diff requires contact precautions, which include a private room and the use of
gloves and gowns. Hand hygiene must be performed with soap and water because alcohol-
based rubs are ineffective against C. diff spores.
,3. A nurse is educating a newly licensed nurse about the ‘Recognize Cues’ step
of the Clinical Judgment Measurement Model. Which of the following actions
should the nurse include?
A. Identifying relevant data from a client’s medical record.
B. Formulating a nursing diagnosis based on data.
C. Predicting potential complications for the client.
D. Deciding which intervention to implement first.
Answer: A
Rationale: Recognizing cues is the first step of the CJMM and involves identifying
significant data (signs, symptoms, lab values) from various sources.
4. A nurse is caring for a client who is falling. Which of the following actions
should the nurse take?
A. Hold the client upright to prevent them from hitting the floor.
B. Grab the client under the arms and pull them toward a chair.
C. Extend one leg and allow the client to slide down it to the floor.
D. Call for help and wait for assistance before moving the client.
Answer: C
Rationale: If a client begins to fall, the nurse should create a wide base of support, extend
one leg, and allow the client to slide down the leg to the floor to minimize injury for both.
5. Which of the following is the priority action when using the RACE acronym for
fire safety?
A. Activate the fire alarm system.
B. Confine the fire by closing doors and windows.
C. Extinguish the fire using a portable extinguisher.
D. Rescue and move clients to a safe area.
Answer: D
, Rationale: In the RACE acronym (Rescue, Alarm, Confine, Extinguish), the priority is
always to rescue and protect clients in immediate danger.
6. A nurse is assessing a client’s radial pulse and notes it is irregular. Which of
the following actions should the nurse take?
A. Wait 10 minutes and reassess the radial pulse.
B. Assess the apical pulse for one full minute.
C. Document the pulse as ‘normal for the client.’
D. Request a stat electrocardiogram (ECG).
Answer: B
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain an accurate heart rate and rhythm.
7. A nurse is preparing to administer an intramuscular (IM) injection. Which of
the following is the preferred site for a large volume injection in an adult?
A. Ventrogluteal
B. Dorsogluteal
C. Deltoid
D. Vastus lateralis
Answer: A
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is deep and away from major blood vessels and nerves.
8. A client who is non-verbal appears restless and is grimacing. Which of the
following pain scales should the nurse use?
A. Numerical Rating Scale (0-10)
B. Wong-Baker FACES Scale
C. FLACC Scale
D. Visual Analog Scale
Answer: C
