1
ATI ClInICAl JudgmenT AssessmenT well
wrITTen one yeAr 2025 /2026 updATed
grAded A+AdvAnCed ClInICAl reAsonIng
exAmInATIon — versIon 3.1 ComprehensIve 150-
QuesTIon exAmInATIon wITh InTegrATed nexT
generATIon nClex ClInICAl JudgmenT
meAsuremenT model And AdvAnCed prACTICe
sCenArIos
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing a comprehensive admission assessment on a 78-year-old client with a history of
hypertension, type 2 diabetes, and osteoarthritis who presents with altered mental status, fever, and
generalized weakness. Which assessment finding should the nurse recognize as the most critical cue
requiring immediate intervention?
A) Client reports joint pain rated 5/10 in bilateral knees
B) Client's blood glucose is 185 mg/dL
C) Client's temperature is 38.9°C (102.0°F) with associated tachycardia
D) Client is oriented to person only and unable to state current location
- deTAIled Answer 100 % CorreCT :-D
Rationale: Altered mental status with disorientation to place and time in an elderly client with fever
suggests possible sepsis, delirium, or meningitis. This represents acute neurological change requiring
immediate comprehensive assessment. While fever with tachycardia is concerning, the altered mental
status indicates potential central nervous system involvement or severe systemic infection. Elevated
blood glucose and joint pain are concerning but do not indicate the same level of acute deterioration.
, 2
Question 2
A nurse is assessing a 65-year-old client who is 3 days post-operative following a total hip
arthroplasty. The client has been receiving morphine patient-controlled analgesia (PCA) for pain
management. Which finding should the nurse recognize as the earliest cue of opioid-induced
respiratory depression?
A) Respiratory rate decreasing from 18 to 12 breaths per minute
B) Oxygen saturation decreasing from 96% to 92%
C) Client becoming increasingly somnolent and difficult to arouse
D) Pupils becoming constricted and sluggish to react
- deTAIled Answer 100 % CorreCT :-A
Rationale: A respiratory rate of 12 breaths per minute represents early opioid-induced respiratory
depression, as the normal rate is 12-20 breaths per minute. While oxygen saturation below 92% is
concerning, it often drops after respiratory rate decreases. Somnolence and difficulty arousing are later
signs of significant respiratory depression. Pupil constriction is an expected opioid effect and not
specifically indicative of respiratory depression.
Question 3
A nurse is reviewing a client's laboratory results from the past 24 hours. The client has a serum sodium
of 118 mEq/L, which has decreased from 132 mEq/L over a 12-hour period. The client has a history of
small cell lung cancer and is receiving chemotherapy. Which finding should the nurse recognize as the
most critical cue?
A) Serum potassium of 3.8 mEq/L
B) Serum glucose of 110 mg/dL
C) The rate of sodium decline and current sodium level
D) White blood cell count of 5,200/mm³
- deTAIled Answer 100 % CorreCT :-C
Rationale: The serum sodium of 118 mEq/L represents severe hyponatremia, and the rapid decline
from 132 to 118 mEq/L over 12 hours significantly increases the risk of cerebral edema and osmotic
demyelination. This rate of decline is critically important and requires urgent intervention. Small cell
lung cancer is associated with syndrome of inappropriate antidiuretic hormone (SIADH), which can
cause severe hyponatremia. Potassium, glucose, and WBC are within normal ranges.
Question 4
A nurse is assessing a 45-year-old client with suspected pulmonary embolism. The client reports
sudden onset of dyspnea, pleuritic chest pain, and hemoptysis. Vital signs: BP 142/88 mmHg, HR
, 3
112/min, RR 32/min, SpO₂ 90% on room air. Which additional finding should the nurse recognize as a
critical cue of a massive pulmonary embolism?
A) The client reports anxiety and fear
B) The client's calf is swollen and tender
C) The client's jugular veins are distended
D) The client reports a dry cough
- deTAIled Answer 100 % CorreCT :-C
Rationale: Jugular venous distention (JVD) in the presence of dyspnea, tachycardia, and hypoxemia
indicates right ventricular strain from a massive pulmonary embolism, potentially progressing to
obstructive shock. JVD suggests increased central venous pressure and right heart failure. Anxiety is
common but nonspecific. Calf swelling suggests DVT (source of embolus) but does not indicate
massive PE. Dry cough is a nonspecific symptom.
Question 5
A nurse is assessing a client who is receiving a continuous IV infusion of heparin for a deep vein
thrombosis. The client's activated partial thromboplastin time (aPTT) is 120 seconds, and the client
reports bleeding gums and has developed a large bruise on the abdomen. Which action should the
nurse recognize as the priority?
A) Document the findings and continue the infusion at the current rate
B) Decrease the heparin infusion rate by 2 units/kg/hour
C) Notify the healthcare provider and prepare to administer protamine sulfate
D) Obtain a complete blood count to assess platelet levels
- deTAIled Answer 100 % CorreCT :-C
Rationale: An aPTT of 120 seconds is significantly elevated (therapeutic range is typically 1.5-2.5 times
control, approximately 60-80 seconds). Active bleeding (bleeding gums, large bruises) indicates
heparin overdose with hemorrhage risk. The nurse must notify the healthcare provider immediately
and prepare to administer protamine sulfate, the antidote for heparin. Simply decreasing the rate is
insufficient given the critical aPTT elevation and active bleeding.
Question 6
A nurse is assessing a 28-year-old client who presents with severe abdominal pain, nausea, and
vomiting. The client reports the pain started in the periumbilical area and has now migrated to the
right lower quadrant. The client is lying on the side with knees flexed. Which finding should the nurse
recognize as a critical cue of peritoneal irritation?
A) Rebound tenderness and guarding in the right lower quadrant
, 4
B) Hyperactive bowel sounds in all four quadrants
C) Client reports pain relief with the application of heat
D) Client reports constipation for the past 2 days
- deTAIled Answer 100 % CorreCT :-A
Rationale: Rebound tenderness and guarding in the right lower quadrant are classic signs of
peritoneal irritation, strongly suggesting appendicitis with possible perforation. The classic migration
of pain from periumbilical to right lower quadrant combined with the fetal position (knees flexed)
further supports appendicitis. Hyperactive bowel sounds may occur early but are not as specific. Heat
application may worsen inflammation. Constipation is a nonspecific symptom.
Question 7
A nurse is performing a focused neurological assessment on a 62-year-old client who had a stroke 6
hours ago. The client has right-sided hemiparesis, expressive aphasia, and facial droop. Which finding
should the nurse recognize as an early cue of increasing intracranial pressure?
A) The client reports a headache rated 5/10
B) The client's Glasgow Coma Scale score decreases from 14 to 12
C) The client's blood pressure increases from 140/90 to 160/92 mmHg
D) The client's pupils remain equal and reactive to light
- deTAIled Answer 100 % CorreCT :-B
Rationale: A decrease in Glasgow Coma Scale (GCS) score from 14 to 12 represents a significant
decline in neurological status, indicating potential increased intracranial pressure or extension of the
stroke. This finding warrants immediate intervention and notification of the healthcare provider.
Headache is common post-stroke. A slight increase in blood pressure may be expected, but a decrease
in GCS is more significant. Equal and reactive pupils are reassuring.
Question 8
A nurse is reviewing a client's medication administration record and notes the client is receiving
digoxin 0.25 mg daily, furosemide 40 mg daily, and lisinopril 10 mg daily. The client reports nausea,
vomiting, and visual disturbances, describing "yellow halos around lights." Which finding should the
nurse recognize as the priority?
A) The client's heart rate is 52 beats per minute
B) The client's serum potassium is 3.2 mEq/L
C) The client's digoxin level is 3.2 ng/mL
D) The client's blood pressure is 138/84 mmHg
ATI ClInICAl JudgmenT AssessmenT well
wrITTen one yeAr 2025 /2026 updATed
grAded A+AdvAnCed ClInICAl reAsonIng
exAmInATIon — versIon 3.1 ComprehensIve 150-
QuesTIon exAmInATIon wITh InTegrATed nexT
generATIon nClex ClInICAl JudgmenT
meAsuremenT model And AdvAnCed prACTICe
sCenArIos
SECTION 1: RECOGNIZE CUES (Assessment)
Question 1
A nurse is performing a comprehensive admission assessment on a 78-year-old client with a history of
hypertension, type 2 diabetes, and osteoarthritis who presents with altered mental status, fever, and
generalized weakness. Which assessment finding should the nurse recognize as the most critical cue
requiring immediate intervention?
A) Client reports joint pain rated 5/10 in bilateral knees
B) Client's blood glucose is 185 mg/dL
C) Client's temperature is 38.9°C (102.0°F) with associated tachycardia
D) Client is oriented to person only and unable to state current location
- deTAIled Answer 100 % CorreCT :-D
Rationale: Altered mental status with disorientation to place and time in an elderly client with fever
suggests possible sepsis, delirium, or meningitis. This represents acute neurological change requiring
immediate comprehensive assessment. While fever with tachycardia is concerning, the altered mental
status indicates potential central nervous system involvement or severe systemic infection. Elevated
blood glucose and joint pain are concerning but do not indicate the same level of acute deterioration.
, 2
Question 2
A nurse is assessing a 65-year-old client who is 3 days post-operative following a total hip
arthroplasty. The client has been receiving morphine patient-controlled analgesia (PCA) for pain
management. Which finding should the nurse recognize as the earliest cue of opioid-induced
respiratory depression?
A) Respiratory rate decreasing from 18 to 12 breaths per minute
B) Oxygen saturation decreasing from 96% to 92%
C) Client becoming increasingly somnolent and difficult to arouse
D) Pupils becoming constricted and sluggish to react
- deTAIled Answer 100 % CorreCT :-A
Rationale: A respiratory rate of 12 breaths per minute represents early opioid-induced respiratory
depression, as the normal rate is 12-20 breaths per minute. While oxygen saturation below 92% is
concerning, it often drops after respiratory rate decreases. Somnolence and difficulty arousing are later
signs of significant respiratory depression. Pupil constriction is an expected opioid effect and not
specifically indicative of respiratory depression.
Question 3
A nurse is reviewing a client's laboratory results from the past 24 hours. The client has a serum sodium
of 118 mEq/L, which has decreased from 132 mEq/L over a 12-hour period. The client has a history of
small cell lung cancer and is receiving chemotherapy. Which finding should the nurse recognize as the
most critical cue?
A) Serum potassium of 3.8 mEq/L
B) Serum glucose of 110 mg/dL
C) The rate of sodium decline and current sodium level
D) White blood cell count of 5,200/mm³
- deTAIled Answer 100 % CorreCT :-C
Rationale: The serum sodium of 118 mEq/L represents severe hyponatremia, and the rapid decline
from 132 to 118 mEq/L over 12 hours significantly increases the risk of cerebral edema and osmotic
demyelination. This rate of decline is critically important and requires urgent intervention. Small cell
lung cancer is associated with syndrome of inappropriate antidiuretic hormone (SIADH), which can
cause severe hyponatremia. Potassium, glucose, and WBC are within normal ranges.
Question 4
A nurse is assessing a 45-year-old client with suspected pulmonary embolism. The client reports
sudden onset of dyspnea, pleuritic chest pain, and hemoptysis. Vital signs: BP 142/88 mmHg, HR
, 3
112/min, RR 32/min, SpO₂ 90% on room air. Which additional finding should the nurse recognize as a
critical cue of a massive pulmonary embolism?
A) The client reports anxiety and fear
B) The client's calf is swollen and tender
C) The client's jugular veins are distended
D) The client reports a dry cough
- deTAIled Answer 100 % CorreCT :-C
Rationale: Jugular venous distention (JVD) in the presence of dyspnea, tachycardia, and hypoxemia
indicates right ventricular strain from a massive pulmonary embolism, potentially progressing to
obstructive shock. JVD suggests increased central venous pressure and right heart failure. Anxiety is
common but nonspecific. Calf swelling suggests DVT (source of embolus) but does not indicate
massive PE. Dry cough is a nonspecific symptom.
Question 5
A nurse is assessing a client who is receiving a continuous IV infusion of heparin for a deep vein
thrombosis. The client's activated partial thromboplastin time (aPTT) is 120 seconds, and the client
reports bleeding gums and has developed a large bruise on the abdomen. Which action should the
nurse recognize as the priority?
A) Document the findings and continue the infusion at the current rate
B) Decrease the heparin infusion rate by 2 units/kg/hour
C) Notify the healthcare provider and prepare to administer protamine sulfate
D) Obtain a complete blood count to assess platelet levels
- deTAIled Answer 100 % CorreCT :-C
Rationale: An aPTT of 120 seconds is significantly elevated (therapeutic range is typically 1.5-2.5 times
control, approximately 60-80 seconds). Active bleeding (bleeding gums, large bruises) indicates
heparin overdose with hemorrhage risk. The nurse must notify the healthcare provider immediately
and prepare to administer protamine sulfate, the antidote for heparin. Simply decreasing the rate is
insufficient given the critical aPTT elevation and active bleeding.
Question 6
A nurse is assessing a 28-year-old client who presents with severe abdominal pain, nausea, and
vomiting. The client reports the pain started in the periumbilical area and has now migrated to the
right lower quadrant. The client is lying on the side with knees flexed. Which finding should the nurse
recognize as a critical cue of peritoneal irritation?
A) Rebound tenderness and guarding in the right lower quadrant
, 4
B) Hyperactive bowel sounds in all four quadrants
C) Client reports pain relief with the application of heat
D) Client reports constipation for the past 2 days
- deTAIled Answer 100 % CorreCT :-A
Rationale: Rebound tenderness and guarding in the right lower quadrant are classic signs of
peritoneal irritation, strongly suggesting appendicitis with possible perforation. The classic migration
of pain from periumbilical to right lower quadrant combined with the fetal position (knees flexed)
further supports appendicitis. Hyperactive bowel sounds may occur early but are not as specific. Heat
application may worsen inflammation. Constipation is a nonspecific symptom.
Question 7
A nurse is performing a focused neurological assessment on a 62-year-old client who had a stroke 6
hours ago. The client has right-sided hemiparesis, expressive aphasia, and facial droop. Which finding
should the nurse recognize as an early cue of increasing intracranial pressure?
A) The client reports a headache rated 5/10
B) The client's Glasgow Coma Scale score decreases from 14 to 12
C) The client's blood pressure increases from 140/90 to 160/92 mmHg
D) The client's pupils remain equal and reactive to light
- deTAIled Answer 100 % CorreCT :-B
Rationale: A decrease in Glasgow Coma Scale (GCS) score from 14 to 12 represents a significant
decline in neurological status, indicating potential increased intracranial pressure or extension of the
stroke. This finding warrants immediate intervention and notification of the healthcare provider.
Headache is common post-stroke. A slight increase in blood pressure may be expected, but a decrease
in GCS is more significant. Equal and reactive pupils are reassuring.
Question 8
A nurse is reviewing a client's medication administration record and notes the client is receiving
digoxin 0.25 mg daily, furosemide 40 mg daily, and lisinopril 10 mg daily. The client reports nausea,
vomiting, and visual disturbances, describing "yellow halos around lights." Which finding should the
nurse recognize as the priority?
A) The client's heart rate is 52 beats per minute
B) The client's serum potassium is 3.2 mEq/L
C) The client's digoxin level is 3.2 ng/mL
D) The client's blood pressure is 138/84 mmHg
