ATI RN CLINICAL JUDGEMENT ASSESMENTS EXAM
NEWEST EVALUATED PRACTICE EXAM 100
QUESTIONS 2026-2027|ORIGINAL QUESTIONS &
ANSWERS |DETAILED RATIONALES |HINTED
COMPLETE EXAM PREP GRADED A+*INSTANT
DOWNLOAD PDF*
1. A nurse is caring for a client who reports crushing substernal chest
pain, diaphoresis, and nausea. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer prescribed morphine
C. Encourage the client to rest
D. Obtain a detailed health history
Answer: A. Obtain a 12-lead ECG
Rationale: A 12-lead ECG should be obtained rapidly when acute
coronary syndrome is suspected because it can identify myocardial
ischemia or infarction and guide immediate treatment.
2. A client with heart failure suddenly develops severe dyspnea, pink
frothy sputum, and bilateral crackles. Which finding requires immediate
intervention?
A. Weight gain of 1 kg in 24 hr
B. Respiratory rate of 30/min
C. Pink frothy sputum
D. 2+ bilateral ankle edema
Answer: C. Pink frothy sputum
,Rationale: Pink frothy sputum is a classic manifestation of acute
pulmonary edema, which can rapidly compromise oxygenation and
requires immediate intervention.
3. A nurse assesses a client receiving IV insulin for diabetic ketoacidosis.
Which finding indicates the treatment is effective?
A. Blood glucose decreases gradually
B. Urine output decreases
C. Respirations become more rapid
D. Serum potassium increases markedly
Answer: A. Blood glucose decreases gradually
Rationale: IV insulin lowers serum glucose and suppresses ketone
production. A gradual reduction in glucose indicates therapeutic
response.
4. A client with a head injury becomes increasingly confused and
develops unequal pupils. What should the nurse do?
A. Reassess in 30 min
B. Notify the provider immediately
C. Administer an oral analgesic
D. Encourage ambulation
Answer: B. Notify the provider immediately
Rationale: Acute neurologic deterioration and unequal pupils can
indicate increased intracranial pressure or herniation and require
emergency evaluation.
,5. A postoperative client has a respiratory rate of 8/min and is difficult
to arouse after receiving IV morphine. Which medication should the
nurse anticipate administering?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression.
6. A client with pneumonia has an oxygen saturation of 86% on room
air. Which action should the nurse take first?
A. Obtain a sputum culture
B. Apply supplemental oxygen
C. Encourage oral fluids
D. Administer an antipyretic
Answer: B. Apply supplemental oxygen
Rationale: Hypoxemia is an immediate threat to life. Supporting
oxygenation takes priority while additional diagnostic and therapeutic
interventions are initiated.
7. A client receiving a blood transfusion develops chills, fever, and low
back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
, C. Administer acetaminophen
D. Obtain another blood sample
Answer: B. Stop the transfusion
Rationale: These findings can indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately to prevent
further exposure to the incompatible blood.
8. A client with hyperkalemia has peaked T waves on the ECG. Which
prescription should the nurse implement first?
A. Oral potassium supplement
B. IV calcium gluconate
C. High-potassium diet
D. Spironolactone
Answer: B. IV calcium gluconate
Rationale: IV calcium stabilizes the cardiac membrane and helps
reduce the immediate risk of life-threatening dysrhythmias from
severe hyperkalemia.
9. A client with COPD is receiving oxygen. Which finding requires the
nurse's immediate attention?
A. Oxygen saturation of 90%
B. Respiratory rate of 18/min
C. Increasing somnolence and confusion
D. Productive cough
Answer: C. Increasing somnolence and confusion
NEWEST EVALUATED PRACTICE EXAM 100
QUESTIONS 2026-2027|ORIGINAL QUESTIONS &
ANSWERS |DETAILED RATIONALES |HINTED
COMPLETE EXAM PREP GRADED A+*INSTANT
DOWNLOAD PDF*
1. A nurse is caring for a client who reports crushing substernal chest
pain, diaphoresis, and nausea. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer prescribed morphine
C. Encourage the client to rest
D. Obtain a detailed health history
Answer: A. Obtain a 12-lead ECG
Rationale: A 12-lead ECG should be obtained rapidly when acute
coronary syndrome is suspected because it can identify myocardial
ischemia or infarction and guide immediate treatment.
2. A client with heart failure suddenly develops severe dyspnea, pink
frothy sputum, and bilateral crackles. Which finding requires immediate
intervention?
A. Weight gain of 1 kg in 24 hr
B. Respiratory rate of 30/min
C. Pink frothy sputum
D. 2+ bilateral ankle edema
Answer: C. Pink frothy sputum
,Rationale: Pink frothy sputum is a classic manifestation of acute
pulmonary edema, which can rapidly compromise oxygenation and
requires immediate intervention.
3. A nurse assesses a client receiving IV insulin for diabetic ketoacidosis.
Which finding indicates the treatment is effective?
A. Blood glucose decreases gradually
B. Urine output decreases
C. Respirations become more rapid
D. Serum potassium increases markedly
Answer: A. Blood glucose decreases gradually
Rationale: IV insulin lowers serum glucose and suppresses ketone
production. A gradual reduction in glucose indicates therapeutic
response.
4. A client with a head injury becomes increasingly confused and
develops unequal pupils. What should the nurse do?
A. Reassess in 30 min
B. Notify the provider immediately
C. Administer an oral analgesic
D. Encourage ambulation
Answer: B. Notify the provider immediately
Rationale: Acute neurologic deterioration and unequal pupils can
indicate increased intracranial pressure or herniation and require
emergency evaluation.
,5. A postoperative client has a respiratory rate of 8/min and is difficult
to arouse after receiving IV morphine. Which medication should the
nurse anticipate administering?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine
Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid-
induced respiratory depression.
6. A client with pneumonia has an oxygen saturation of 86% on room
air. Which action should the nurse take first?
A. Obtain a sputum culture
B. Apply supplemental oxygen
C. Encourage oral fluids
D. Administer an antipyretic
Answer: B. Apply supplemental oxygen
Rationale: Hypoxemia is an immediate threat to life. Supporting
oxygenation takes priority while additional diagnostic and therapeutic
interventions are initiated.
7. A client receiving a blood transfusion develops chills, fever, and low
back pain. What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
, C. Administer acetaminophen
D. Obtain another blood sample
Answer: B. Stop the transfusion
Rationale: These findings can indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately to prevent
further exposure to the incompatible blood.
8. A client with hyperkalemia has peaked T waves on the ECG. Which
prescription should the nurse implement first?
A. Oral potassium supplement
B. IV calcium gluconate
C. High-potassium diet
D. Spironolactone
Answer: B. IV calcium gluconate
Rationale: IV calcium stabilizes the cardiac membrane and helps
reduce the immediate risk of life-threatening dysrhythmias from
severe hyperkalemia.
9. A client with COPD is receiving oxygen. Which finding requires the
nurse's immediate attention?
A. Oxygen saturation of 90%
B. Respiratory rate of 18/min
C. Increasing somnolence and confusion
D. Productive cough
Answer: C. Increasing somnolence and confusion
