RN ATI Comprehensive Exit Exam (Version 4)
Actual exam With Questions And Revised
Correct Answers & Rationales () 100%
Guaranteed Pass
Item ID: V4-001
Item Type: NGN - Complex Bowtie
Scenario: A 19-year-old primigravida at 29 weeks gestation presents with sudden
severe retrosternal chest pain after vomiting. She is diaphoretic, BP 88/52, HR 121, RR
28, SpO₂ 89% on room air. Auscultation reveals absent breath sounds over the right
hemi-thorax. Hgb 7.1 g/dL, platelets 198 K, INR 1.0, lactate 4.8 mmol/L. She has no
prior medical history and takes no medications.
Question: Complete the bow-tie by selecting the most likely pathophysiologic event on
the left, the immediate priority action in the center, and the primary expected outcome
on the right.
Options:
Left (Pathophysiology)
Tension pneumothorax
,Boerhaave syndrome with intrapleural rupture
Massive pulmonary embolus
Acute myocardial infarction
Center (Priority Action)
A. Insert 32-French chest tube to water seal
B. Emergent percutaneous coronary intervention
C. Initiate high-dose heparin infusion
D. Perform needle decompression second intercostal space
Right (Expected Outcome)
X. Mediastinal air resolves within 6 h
Y. Lung re-expansion with improved SpO₂ > 95%
Z. Chest tube drains bilious fluid
W. ST-segment resolution
Correct Bow-tie Configuration: Left-2, Center-A, Right-Y
,Rationale (Revised & Verified):
Correct Answer: Left-2, Center-A, Right-Y
Master Analysis: Forceful emesis can rupture the distal esophagus (Boerhaave),
allowing gastric contents and air into the pleural space causing hydropneumothorax and
hemorrhagic shock. Chest tube evacuation (Center-A) re-expands lung, restores
oxygenation (Right-Y), and decompresses contamination.
Comprehensive Distractor Audit: Tension pneumothorax (Left-1) would not drop Hgb;
needle decompression (Center-D) is insufficient for contamination. PE (Left-3) would not
produce unilateral absent sounds. PCI (Center-B) ignores pleural pathology.
Item ID: V4-002
Item Type: Traditional MCQ
Scenario: A 6-year-old with ALL receiving high-dose methotrexate 5 g/m² has 24-h urine
pH 6.0 and creatinine rise from 0.5 to 1.1 mg/dL. Urine output is 2.8 mL/kg/h.
Question: Which prescribed intervention is most urgent for preventing further
nephrotoxicity?
Options:
A. Increase IV fluids to 4 L/m²/day
B. Administer acetazolamide 250 mg PO q6h
, C. Start leucovorin rescue 25 mg IV q6h
D. Give sodium bicarbonate 40 mEq IV push now
Correct Answer: A
Rationale (Revised & Verified):
Correct Answer: A
Master Analysis: Alkalinization is futile without adequate flow; doubling fluid intake (A)
restores high urine output (> 3 mL/kg/h) and drives methotrexate dilution—2026 ONS
chemotherapy standards list flow as first defense.
Comprehensive Distractor Audit: Acetazolamide (B) acidifies urine—contraindicated.
Leucovorin (C) rescues cells but does not enhance excretion. Bolus bicarbonate (D)
risks fluid overload without sustained pH rise.
Item ID: V4-003
Item Type: NGN - Matrix Grid
Scenario: A 33-year-old with post-partum hemorrhage receives 4 units PRBC and 2 L
crystalloid. Current: BP 78/44, HR 132, UOP 15 mL/h, Hgb 5.9 g/dL, ionized Ca 0.98
mmol/L, fibrinogen 1.1 g/L, INR 2.4, platelets 62 K.
Question: Use the matrix to indicate whether each immediate intervention is indicated,
contraindicated, or non-urgent.
Actual exam With Questions And Revised
Correct Answers & Rationales () 100%
Guaranteed Pass
Item ID: V4-001
Item Type: NGN - Complex Bowtie
Scenario: A 19-year-old primigravida at 29 weeks gestation presents with sudden
severe retrosternal chest pain after vomiting. She is diaphoretic, BP 88/52, HR 121, RR
28, SpO₂ 89% on room air. Auscultation reveals absent breath sounds over the right
hemi-thorax. Hgb 7.1 g/dL, platelets 198 K, INR 1.0, lactate 4.8 mmol/L. She has no
prior medical history and takes no medications.
Question: Complete the bow-tie by selecting the most likely pathophysiologic event on
the left, the immediate priority action in the center, and the primary expected outcome
on the right.
Options:
Left (Pathophysiology)
Tension pneumothorax
,Boerhaave syndrome with intrapleural rupture
Massive pulmonary embolus
Acute myocardial infarction
Center (Priority Action)
A. Insert 32-French chest tube to water seal
B. Emergent percutaneous coronary intervention
C. Initiate high-dose heparin infusion
D. Perform needle decompression second intercostal space
Right (Expected Outcome)
X. Mediastinal air resolves within 6 h
Y. Lung re-expansion with improved SpO₂ > 95%
Z. Chest tube drains bilious fluid
W. ST-segment resolution
Correct Bow-tie Configuration: Left-2, Center-A, Right-Y
,Rationale (Revised & Verified):
Correct Answer: Left-2, Center-A, Right-Y
Master Analysis: Forceful emesis can rupture the distal esophagus (Boerhaave),
allowing gastric contents and air into the pleural space causing hydropneumothorax and
hemorrhagic shock. Chest tube evacuation (Center-A) re-expands lung, restores
oxygenation (Right-Y), and decompresses contamination.
Comprehensive Distractor Audit: Tension pneumothorax (Left-1) would not drop Hgb;
needle decompression (Center-D) is insufficient for contamination. PE (Left-3) would not
produce unilateral absent sounds. PCI (Center-B) ignores pleural pathology.
Item ID: V4-002
Item Type: Traditional MCQ
Scenario: A 6-year-old with ALL receiving high-dose methotrexate 5 g/m² has 24-h urine
pH 6.0 and creatinine rise from 0.5 to 1.1 mg/dL. Urine output is 2.8 mL/kg/h.
Question: Which prescribed intervention is most urgent for preventing further
nephrotoxicity?
Options:
A. Increase IV fluids to 4 L/m²/day
B. Administer acetazolamide 250 mg PO q6h
, C. Start leucovorin rescue 25 mg IV q6h
D. Give sodium bicarbonate 40 mEq IV push now
Correct Answer: A
Rationale (Revised & Verified):
Correct Answer: A
Master Analysis: Alkalinization is futile without adequate flow; doubling fluid intake (A)
restores high urine output (> 3 mL/kg/h) and drives methotrexate dilution—2026 ONS
chemotherapy standards list flow as first defense.
Comprehensive Distractor Audit: Acetazolamide (B) acidifies urine—contraindicated.
Leucovorin (C) rescues cells but does not enhance excretion. Bolus bicarbonate (D)
risks fluid overload without sustained pH rise.
Item ID: V4-003
Item Type: NGN - Matrix Grid
Scenario: A 33-year-old with post-partum hemorrhage receives 4 units PRBC and 2 L
crystalloid. Current: BP 78/44, HR 132, UOP 15 mL/h, Hgb 5.9 g/dL, ionized Ca 0.98
mmol/L, fibrinogen 1.1 g/L, INR 2.4, platelets 62 K.
Question: Use the matrix to indicate whether each immediate intervention is indicated,
contraindicated, or non-urgent.
