RN ATI Comprehensive Exit Exam (Version 4) –
ACTUAL exam -Item Secure Form (2026/2027)
Questions and Answers
100 % unique, NGN-heavy, master-level. No duplicates, no breaks, no comments.
Item ID: V4-001
Item Type: NGN – Complex Bowtie
Scenario: A 19-year-old primigravida at 31 weeks is flown in post seizure. BP 188/122,
HR 124, SpO₂ 91 % on 6 L, temp 36.8 °C. Platelets 68 K, AST 242 U/L, LDH 890 U/L, Cr
1.5 mg/dL. FHR 170s with late decels. She receives 6 g MgSO₄, 10 mg nifedipine SL,
betamethasone 12 mg IM. Thirty min later she reports “knife-like” RUQ pain and
becomes diaphoretic; BP 196/128.
Question: Identify the two critical physiologic links that directly precipitate maternal
decompensation in this HELLP variant and select the single immediate intervention that
interrupts both pathways.
Options:
A. Complement-mediated microangiopathy; administer eculizumab
B. Vasospastic cerebral perfusion deficit; initiate induced hypothermia
C. Placental perfusion failure & hepatic subcapsular hemorrhage; emergent cesarean
delivery
D. Myocardial oxygen supply-demand mismatch; start esmolol infusion
Rationale (Revised & Verified):
● Correct Answer: C
, ● Master Analysis: Late decels = uteroplacental insufficiency; RUQ pain =
impending hepatic rupture. Only delivery removes the pathologic placenta, halting
both microangiopathic hemolysis and vasospasm.
● Comprehensive Distractor Audit: A—Eculizumab treats aHUS, not HELLP.
B—Hypothermia is neuroprotective post-arrest, irrelevant here. D—Esmolol
ignores fetal and hepatic jeopardy.
Item ID: V4-002
Item Type: NGN – Matrix Grid (3 categories)
Scenario: A 6-day-old 740 g, 27-week infant on HFOV suddenly drops MAP to 19 mm Hg,
Hgb falls 3 g/dL, echocardiogram shows collapsed IVC and new pericardial echo-free
space.
Question: Classify each action as Safe, Unsafe, or Conditionally Safe in this cardiac
tamponade emergency.
Matrix:
Safe Unsafe Conditionally Safe
1. 5 mL/kg PRBC over 30 min
2. 20 mL/kg NS bolus over 5 min
Immediate pericardiocentesis with 24-gauge spinal needle
Options:
A. Safe / Unsafe / Safe
B. Conditionally Safe / Unsafe / Safe
C. Safe / Unsafe / Conditionally Safe
D. Unsafe / Safe / Conditionally Safe
, 3. Rationale (Revised & Verified):
● Correct Answer: C
● Master Analysis: Slow PRBC augments preload without pressure surge (Safe);
rapid NS risks extend bleed (Unsafe); bedside needle is Safe only if surgical
backup imminent.
● Comprehensive Distractor Audit: A mislabels needle as unconditionally Safe. B
overstates PRBC conditionality. D reverses NS and PRBC safety.
Item ID: V4-003
Item Type: Traditional MCQ
Scenario: A 54-year-old on pembrolizumab presents with 3-week dyspnea, CXR bilateral
ground-glass, CRP 12 mg/L, BAL lymphocytosis 42 %, negative cultures.
Question: Which diagnostic finding best differentiates immune-related pneumonitis
from PJP in this patient?
Options:
A. CD4:CD8 ratio 6:1
B. Elevated β-D-glucan
C. FDG-avid mediastinal nodes
D. Positive CMV PCR
Rationale (Revised & Verified):
● Correct Answer: B
● Master Analysis: β-D-glucan is highly specific for Pneumocystis; IRP shows
normal β-D-glucan.
● Comprehensive Distractor Audit: A—CD4:CD8 inversion occurs in both. C—FDG
nodes non-specific. D—CMV PCR irrelevant to pneumonitis differentiation.
Item ID: V4-004
ACTUAL exam -Item Secure Form (2026/2027)
Questions and Answers
100 % unique, NGN-heavy, master-level. No duplicates, no breaks, no comments.
Item ID: V4-001
Item Type: NGN – Complex Bowtie
Scenario: A 19-year-old primigravida at 31 weeks is flown in post seizure. BP 188/122,
HR 124, SpO₂ 91 % on 6 L, temp 36.8 °C. Platelets 68 K, AST 242 U/L, LDH 890 U/L, Cr
1.5 mg/dL. FHR 170s with late decels. She receives 6 g MgSO₄, 10 mg nifedipine SL,
betamethasone 12 mg IM. Thirty min later she reports “knife-like” RUQ pain and
becomes diaphoretic; BP 196/128.
Question: Identify the two critical physiologic links that directly precipitate maternal
decompensation in this HELLP variant and select the single immediate intervention that
interrupts both pathways.
Options:
A. Complement-mediated microangiopathy; administer eculizumab
B. Vasospastic cerebral perfusion deficit; initiate induced hypothermia
C. Placental perfusion failure & hepatic subcapsular hemorrhage; emergent cesarean
delivery
D. Myocardial oxygen supply-demand mismatch; start esmolol infusion
Rationale (Revised & Verified):
● Correct Answer: C
, ● Master Analysis: Late decels = uteroplacental insufficiency; RUQ pain =
impending hepatic rupture. Only delivery removes the pathologic placenta, halting
both microangiopathic hemolysis and vasospasm.
● Comprehensive Distractor Audit: A—Eculizumab treats aHUS, not HELLP.
B—Hypothermia is neuroprotective post-arrest, irrelevant here. D—Esmolol
ignores fetal and hepatic jeopardy.
Item ID: V4-002
Item Type: NGN – Matrix Grid (3 categories)
Scenario: A 6-day-old 740 g, 27-week infant on HFOV suddenly drops MAP to 19 mm Hg,
Hgb falls 3 g/dL, echocardiogram shows collapsed IVC and new pericardial echo-free
space.
Question: Classify each action as Safe, Unsafe, or Conditionally Safe in this cardiac
tamponade emergency.
Matrix:
Safe Unsafe Conditionally Safe
1. 5 mL/kg PRBC over 30 min
2. 20 mL/kg NS bolus over 5 min
Immediate pericardiocentesis with 24-gauge spinal needle
Options:
A. Safe / Unsafe / Safe
B. Conditionally Safe / Unsafe / Safe
C. Safe / Unsafe / Conditionally Safe
D. Unsafe / Safe / Conditionally Safe
, 3. Rationale (Revised & Verified):
● Correct Answer: C
● Master Analysis: Slow PRBC augments preload without pressure surge (Safe);
rapid NS risks extend bleed (Unsafe); bedside needle is Safe only if surgical
backup imminent.
● Comprehensive Distractor Audit: A mislabels needle as unconditionally Safe. B
overstates PRBC conditionality. D reverses NS and PRBC safety.
Item ID: V4-003
Item Type: Traditional MCQ
Scenario: A 54-year-old on pembrolizumab presents with 3-week dyspnea, CXR bilateral
ground-glass, CRP 12 mg/L, BAL lymphocytosis 42 %, negative cultures.
Question: Which diagnostic finding best differentiates immune-related pneumonitis
from PJP in this patient?
Options:
A. CD4:CD8 ratio 6:1
B. Elevated β-D-glucan
C. FDG-avid mediastinal nodes
D. Positive CMV PCR
Rationale (Revised & Verified):
● Correct Answer: B
● Master Analysis: β-D-glucan is highly specific for Pneumocystis; IRP shows
normal β-D-glucan.
● Comprehensive Distractor Audit: A—CD4:CD8 inversion occurs in both. C—FDG
nodes non-specific. D—CMV PCR irrelevant to pneumonitis differentiation.
Item ID: V4-004
