RN ATI CONCEPT-BASED ASSESSMENT
PROCTORED EXAM SCRIPT 2026
◉ A nurse is caring for a client who has a pneumothorax and a
closed-chest drainage system. Which of the following findings is an
indication of lung re-expansion? Answer: Bubbling in the water seal
chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung
re-expands.
◉ A nurse is reviewing the medical record of a client who is taking
warfarin for chronic atrial fibrillation. Which of the following values
should the nurse identify as a desired outcome for this therapy?
Answer: INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of
stroke, myocardial infarction (MI), or pulmonary emboli (PE) from
blood clots. Since warfarin is an anticoagulant, the medication must
be monitored to ensure the anticoagulation is within the therapeutic
range and prevent hemorrhage (high levels of anticoagulation) or
stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is
within the targeted therapeutic range of 2 to 3 for a client who has
atrial fibrillation.
◉ A home health nurse is providing teaching to a client who has a
stage 1 pressure injury on the greater trochanter of his left hip.
,Which of the following instructions should the nurse include in the
teaching? Answer: Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on
bony prominences. The nurse should also instruct the client to limit
the angle of the hips when in a lateral position to no more than 30°.
This positioning prevents direct pressure on the trochanter.
◉ A nurse is assessing a client following the completion of
hemodialysis. Which of the following findings is the nurse's priority
to report to the provider? Answer: Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding to report to the
provider is restlessness, which can be an indication the client is
experiencing disequilibrium syndrome. Disequilibrium syndrome is
caused by the rapid removal of electrolytes from the client's blood
and can lead to dysrhythmias or seizures. Other manifestations
include nausea, vomiting, fatigue, and headache.
◉ A nurse is caring for a client who is 8 hr postoperative following a
total hip arthroplasty. The client is unable to void on the bedpan.
Which of the following actions should the nurse take first? Answer:
Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing
process is to assess the client. Scanning the bladder with a portable
ultrasound device will determine the amount of urine in the bladder
,◉ A nurse is planning a health promotional presentation for a group
of African American clients at a community center. Which of the
following disorders presents the greatest risk to this group of
clients? Answer: Hypertension
Rationale: When using the safety/risk reduction approach to client
care, the nurse should determine that the disorder with the greatest
risk for this group of clients is hypertension. The prevalence of
hypertension is highest among African American clients, followed by
Caucasian clients, and then Hispanic clients.
◉ A nurse is caring for a client who has DKA. Which of the following
findings should indicate to the nurse that the client's condition is
improving? Answer: Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates
improvement in the client's status.
◉ A nurse is caring for a client following extubation of an
endotracheal tube 10 min. ago. Which of the following findings
should the nurse report to the provider immediately? Answer:
Stridor
Rationale: Using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding is stridor.
Stridor can indicate a narrowing airway or possible obstruction
caused by edema or laryngeal spasms. The nurse should report the
finding immediately and implement an intervention.
, ◉ A nurse is caring for a client who had a nephrostomy tube
inserted 112 hr ago. Which of the following findings should the
nurse report to the provider? Answer: The client reports back pain
Rationale: The nurse should notify the provider if the client reports
back pain, which can indicate that the nephrostomy tube is
dislodged or clogged.
◉ A nurse is admitting a client who has active TB. Which of the
following types of transmission precautions should the nurse
initiate? Answer: Airborne
Rationale: Airborne precautions are required for clients who have
infections due to micro-organisms that can remain suspended in air
for lengthy periods of time, such as tuberculosis, measles, varicella,
and disseminated varicella zoster.
◉ A nurse is planning care for a client who has a sealed radiation
implant for cervical cancer. Which of the following interventions
should the nurse include in the plan of care? Answer: Keep a lead-
lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps
in the client's room in case of accidental dislodgement of the
implant.
◉ A nurse is assessing a client who is postoperative following a
thyroidectomy. Which of the following findings is the nurse's
priority? Answer: Temperature 38.9° C (102° F)
PROCTORED EXAM SCRIPT 2026
◉ A nurse is caring for a client who has a pneumothorax and a
closed-chest drainage system. Which of the following findings is an
indication of lung re-expansion? Answer: Bubbling in the water seal
chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung
re-expands.
◉ A nurse is reviewing the medical record of a client who is taking
warfarin for chronic atrial fibrillation. Which of the following values
should the nurse identify as a desired outcome for this therapy?
Answer: INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of
stroke, myocardial infarction (MI), or pulmonary emboli (PE) from
blood clots. Since warfarin is an anticoagulant, the medication must
be monitored to ensure the anticoagulation is within the therapeutic
range and prevent hemorrhage (high levels of anticoagulation) or
stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is
within the targeted therapeutic range of 2 to 3 for a client who has
atrial fibrillation.
◉ A home health nurse is providing teaching to a client who has a
stage 1 pressure injury on the greater trochanter of his left hip.
,Which of the following instructions should the nurse include in the
teaching? Answer: Change position every hour
Rationale: Changing position every 1 to 2 hr decreases pressure on
bony prominences. The nurse should also instruct the client to limit
the angle of the hips when in a lateral position to no more than 30°.
This positioning prevents direct pressure on the trochanter.
◉ A nurse is assessing a client following the completion of
hemodialysis. Which of the following findings is the nurse's priority
to report to the provider? Answer: Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding to report to the
provider is restlessness, which can be an indication the client is
experiencing disequilibrium syndrome. Disequilibrium syndrome is
caused by the rapid removal of electrolytes from the client's blood
and can lead to dysrhythmias or seizures. Other manifestations
include nausea, vomiting, fatigue, and headache.
◉ A nurse is caring for a client who is 8 hr postoperative following a
total hip arthroplasty. The client is unable to void on the bedpan.
Which of the following actions should the nurse take first? Answer:
Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing
process is to assess the client. Scanning the bladder with a portable
ultrasound device will determine the amount of urine in the bladder
,◉ A nurse is planning a health promotional presentation for a group
of African American clients at a community center. Which of the
following disorders presents the greatest risk to this group of
clients? Answer: Hypertension
Rationale: When using the safety/risk reduction approach to client
care, the nurse should determine that the disorder with the greatest
risk for this group of clients is hypertension. The prevalence of
hypertension is highest among African American clients, followed by
Caucasian clients, and then Hispanic clients.
◉ A nurse is caring for a client who has DKA. Which of the following
findings should indicate to the nurse that the client's condition is
improving? Answer: Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates
improvement in the client's status.
◉ A nurse is caring for a client following extubation of an
endotracheal tube 10 min. ago. Which of the following findings
should the nurse report to the provider immediately? Answer:
Stridor
Rationale: Using the urgent vs. nonurgent approach to client care,
the nurse should determine that the priority finding is stridor.
Stridor can indicate a narrowing airway or possible obstruction
caused by edema or laryngeal spasms. The nurse should report the
finding immediately and implement an intervention.
, ◉ A nurse is caring for a client who had a nephrostomy tube
inserted 112 hr ago. Which of the following findings should the
nurse report to the provider? Answer: The client reports back pain
Rationale: The nurse should notify the provider if the client reports
back pain, which can indicate that the nephrostomy tube is
dislodged or clogged.
◉ A nurse is admitting a client who has active TB. Which of the
following types of transmission precautions should the nurse
initiate? Answer: Airborne
Rationale: Airborne precautions are required for clients who have
infections due to micro-organisms that can remain suspended in air
for lengthy periods of time, such as tuberculosis, measles, varicella,
and disseminated varicella zoster.
◉ A nurse is planning care for a client who has a sealed radiation
implant for cervical cancer. Which of the following interventions
should the nurse include in the plan of care? Answer: Keep a lead-
lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps
in the client's room in case of accidental dislodgement of the
implant.
◉ A nurse is assessing a client who is postoperative following a
thyroidectomy. Which of the following findings is the nurse's
priority? Answer: Temperature 38.9° C (102° F)
