ATI ClInICAl JudgmenT
AssessmenT ComprehensIve
exAmInATIon — 150 mulTIple-ChoICe
QuesTIons well wrITTen one yeAr 2025
/2026 updATed grAded A+
EXAM TITLE: ATI Clinical Judgment Assessment: Advanced Clinical
Reasoning, Priority-Setting, and Next Generation NCLEX Clinical
Judgment Measurement Model Integration for High-Stakes Nursing
Licensure Readiness
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing an initial assessment on a 72-year-old client admitted with shortness of
breath. Which finding should the nurse recognize as the most significant cue requiring
immediate further investigation?
A) Client reports occasional coughing with clear sputum
B) Client has a history of hypertension controlled with medication
C) Client demonstrates jugular venous distention while sitting at 45 degrees
D) Client's skin is warm and dry to touch
- deTAIled Answer 100 % CorreCT :-C
Rationale: Jugular venous distention (JVD) is a significant clinical cue indicating increased
central venous pressure, commonly associated with right-sided heart failure, pulmonary
,hypertension, or pericardial effusion. This finding warrants immediate further investigation as it
suggests hemodynamic compromise. Clear sputum with occasional coughing, controlled
hypertension, and warm dry skin are less concerning findings that do not indicate acute
deterioration.
Question 2
A nurse is reviewing a client's electronic health record. Which piece of information represents a
subjective cue that the nurse should document?
A) Blood pressure 142/88 mmHg
B) Serum potassium 3.4 mEq/L
C) Client states, "I feel like my heart is racing"
D) Oxygen saturation 94% on room air
- deTAIled Answer 100 % CorreCT :-C
Rationale: Subjective data are information reported by the client and cannot be independently
verified by the nurse. The client's statement about feeling heart racing is subjective. Blood
pressure, serum potassium, and oxygen saturation are objective data that can be measured
and verified.
Question 3
A nurse is assessing a client who reports abdominal pain. Which assessment technique should
the nurse use to recognize cues related to peritoneal irritation?
A) Auscultation of bowel sounds in all four quadrants
B) Palpation for rebound tenderness and guarding
C) Percussion for tympany over the gastric bubble
D) Inspection for abdominal distention and skin changes
- deTAIled Answer 100 % CorreCT :-B
Rationale: Rebound tenderness and guarding are classic cues of peritoneal irritation, which
may indicate appendicitis, peritonitis, or other intra-abdominal pathology. While all assessment
techniques provide valuable information, palpation for rebound tenderness directly assesses
for peritoneal signs. Auscultation, percussion, and inspection provide supportive but less
specific data.
,Question 4
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).
Which assessment finding should the nurse recognize as an early cue of respiratory decline?
A) Increased anteroposterior chest diameter
B) Use of accessory muscles during inspiration
C) Pursed-lip breathing during exhalation
D) Barrel-shaped chest appearance
- deTAIled Answer 100 % CorreCT :-B
Rationale: Use of accessory muscles (sternocleidomastoid, trapezius, intercostal muscles)
during inspiration is an early cue of increased work of breathing and impending respiratory
compromise. Barrel-shaped chest and pursed-lip breathing are chronic adaptations in COPD
patients. Increased AP diameter is a structural change that develops over time.
Question 5
A nurse is assessing a client who underwent abdominal surgery 24 hours ago. Which cue
should the nurse recognize as an early sign of a potential wound infection?
A) Serosanguineous drainage on the dressing
B) Temperature of 37.8°C (100.0°F)
C) Erythema extending 2 cm from the incision site
D) Client reports pain at the incision site rated 4/10
- deTAIled Answer 100 % CorreCT :-C
Rationale: Erythema (redness) extending beyond the immediate wound edges is an early cue
of inflammation and potential infection. While fever may indicate infection, low-grade fever
can be a normal postoperative response. Serosanguineous drainage is expected in the first 24-
48 hours. Pain is expected postoperatively.
Question 6
A nurse is performing a neurological assessment on a client following a stroke. Which finding
should the nurse recognize as the most concerning cue?
A) Client has mild dysarthria when speaking
B) Client's Glasgow Coma Scale score decreases from 15 to 13
, C) Client reports a headache rated 4/10
D) Client has slight weakness in the right upper extremity
- deTAIled Answer 100 % CorreCT :-B
Rationale: A decrease in Glasgow Coma Scale score from 15 to 13 represents a significant
decline in neurological status, indicating potential increased intracranial pressure or extension
of the stroke. This requires immediate intervention. Mild dysarthria, slight weakness, and mild
headache are concerning but do not indicate the same level of acute deterioration.
Question 7
A nurse is reviewing laboratory results for a client with chronic kidney disease. Which
laboratory value should the nurse recognize as a critical cue requiring immediate notification
of the healthcare provider?
A) Serum creatinine 2.8 mg/dL (baseline 2.5 mg/dL)
B) Serum potassium 6.8 mEq/L
C) Blood urea nitrogen 45 mg/dL
D) Hemoglobin 10.2 g/dL
- deTAIled Answer 100 % CorreCT :-B
Rationale: A serum potassium of 6.8 mEq/L represents severe hyperkalemia, which can cause
life-threatening cardiac dysrhythmias. This is a critical value requiring immediate intervention.
While elevated creatinine and BUN are expected in chronic kidney disease, they do not pose
the same immediate threat. Mild anemia is common in CKD and does not require emergent
intervention.
Question 8
A nurse is assessing a client receiving a blood transfusion. Which cue should the nurse
recognize as an early sign of a transfusion reaction?
A) Client reports a mild headache
B) Client's temperature increases from 37.0°C to 37.8°C (98.6°F to 100.0°F)
C) Client develops low back pain and chills
D) Client's heart rate increases from 76 to 82 beats per minute
AssessmenT ComprehensIve
exAmInATIon — 150 mulTIple-ChoICe
QuesTIons well wrITTen one yeAr 2025
/2026 updATed grAded A+
EXAM TITLE: ATI Clinical Judgment Assessment: Advanced Clinical
Reasoning, Priority-Setting, and Next Generation NCLEX Clinical
Judgment Measurement Model Integration for High-Stakes Nursing
Licensure Readiness
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing an initial assessment on a 72-year-old client admitted with shortness of
breath. Which finding should the nurse recognize as the most significant cue requiring
immediate further investigation?
A) Client reports occasional coughing with clear sputum
B) Client has a history of hypertension controlled with medication
C) Client demonstrates jugular venous distention while sitting at 45 degrees
D) Client's skin is warm and dry to touch
- deTAIled Answer 100 % CorreCT :-C
Rationale: Jugular venous distention (JVD) is a significant clinical cue indicating increased
central venous pressure, commonly associated with right-sided heart failure, pulmonary
,hypertension, or pericardial effusion. This finding warrants immediate further investigation as it
suggests hemodynamic compromise. Clear sputum with occasional coughing, controlled
hypertension, and warm dry skin are less concerning findings that do not indicate acute
deterioration.
Question 2
A nurse is reviewing a client's electronic health record. Which piece of information represents a
subjective cue that the nurse should document?
A) Blood pressure 142/88 mmHg
B) Serum potassium 3.4 mEq/L
C) Client states, "I feel like my heart is racing"
D) Oxygen saturation 94% on room air
- deTAIled Answer 100 % CorreCT :-C
Rationale: Subjective data are information reported by the client and cannot be independently
verified by the nurse. The client's statement about feeling heart racing is subjective. Blood
pressure, serum potassium, and oxygen saturation are objective data that can be measured
and verified.
Question 3
A nurse is assessing a client who reports abdominal pain. Which assessment technique should
the nurse use to recognize cues related to peritoneal irritation?
A) Auscultation of bowel sounds in all four quadrants
B) Palpation for rebound tenderness and guarding
C) Percussion for tympany over the gastric bubble
D) Inspection for abdominal distention and skin changes
- deTAIled Answer 100 % CorreCT :-B
Rationale: Rebound tenderness and guarding are classic cues of peritoneal irritation, which
may indicate appendicitis, peritonitis, or other intra-abdominal pathology. While all assessment
techniques provide valuable information, palpation for rebound tenderness directly assesses
for peritoneal signs. Auscultation, percussion, and inspection provide supportive but less
specific data.
,Question 4
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD).
Which assessment finding should the nurse recognize as an early cue of respiratory decline?
A) Increased anteroposterior chest diameter
B) Use of accessory muscles during inspiration
C) Pursed-lip breathing during exhalation
D) Barrel-shaped chest appearance
- deTAIled Answer 100 % CorreCT :-B
Rationale: Use of accessory muscles (sternocleidomastoid, trapezius, intercostal muscles)
during inspiration is an early cue of increased work of breathing and impending respiratory
compromise. Barrel-shaped chest and pursed-lip breathing are chronic adaptations in COPD
patients. Increased AP diameter is a structural change that develops over time.
Question 5
A nurse is assessing a client who underwent abdominal surgery 24 hours ago. Which cue
should the nurse recognize as an early sign of a potential wound infection?
A) Serosanguineous drainage on the dressing
B) Temperature of 37.8°C (100.0°F)
C) Erythema extending 2 cm from the incision site
D) Client reports pain at the incision site rated 4/10
- deTAIled Answer 100 % CorreCT :-C
Rationale: Erythema (redness) extending beyond the immediate wound edges is an early cue
of inflammation and potential infection. While fever may indicate infection, low-grade fever
can be a normal postoperative response. Serosanguineous drainage is expected in the first 24-
48 hours. Pain is expected postoperatively.
Question 6
A nurse is performing a neurological assessment on a client following a stroke. Which finding
should the nurse recognize as the most concerning cue?
A) Client has mild dysarthria when speaking
B) Client's Glasgow Coma Scale score decreases from 15 to 13
, C) Client reports a headache rated 4/10
D) Client has slight weakness in the right upper extremity
- deTAIled Answer 100 % CorreCT :-B
Rationale: A decrease in Glasgow Coma Scale score from 15 to 13 represents a significant
decline in neurological status, indicating potential increased intracranial pressure or extension
of the stroke. This requires immediate intervention. Mild dysarthria, slight weakness, and mild
headache are concerning but do not indicate the same level of acute deterioration.
Question 7
A nurse is reviewing laboratory results for a client with chronic kidney disease. Which
laboratory value should the nurse recognize as a critical cue requiring immediate notification
of the healthcare provider?
A) Serum creatinine 2.8 mg/dL (baseline 2.5 mg/dL)
B) Serum potassium 6.8 mEq/L
C) Blood urea nitrogen 45 mg/dL
D) Hemoglobin 10.2 g/dL
- deTAIled Answer 100 % CorreCT :-B
Rationale: A serum potassium of 6.8 mEq/L represents severe hyperkalemia, which can cause
life-threatening cardiac dysrhythmias. This is a critical value requiring immediate intervention.
While elevated creatinine and BUN are expected in chronic kidney disease, they do not pose
the same immediate threat. Mild anemia is common in CKD and does not require emergent
intervention.
Question 8
A nurse is assessing a client receiving a blood transfusion. Which cue should the nurse
recognize as an early sign of a transfusion reaction?
A) Client reports a mild headache
B) Client's temperature increases from 37.0°C to 37.8°C (98.6°F to 100.0°F)
C) Client develops low back pain and chills
D) Client's heart rate increases from 76 to 82 beats per minute
