RN ATI Comprehensive Exit Exam (Version 3) Actual
exam With Questions And Revised Correct Answers
& Rationales (2026/2027) 100% Guaranteed Pass
Item ID: V3-001
Item Type: NGN - Bowtie
Scenario:
A 67-year-old cisgender woman with heart-failure-reduced ejection fraction 30%, type-2
diabetes on insulin glargine 20 U hs, CKD G4 (eGFR 25 mL/min), and COPD GOLD-3 is
admitted with 3-day dyspnea, bilateral edema, and S3 gallop. Admission labs: Na 128
mmol/L, K 5.3 mmol/L, Cl 94 mmol/L, CO₂ 18 mmol/L, BUN 52 mg/dL, Scr 2.1 mg/dL,
glucose 312 mg/dL, HbA1c 9.4%. Home meds include metformin 1000 mg BID,
furosemide 80 mg PO BID, digoxin 0.25 mg daily, and tiotropium. Vital signs: BP 88/52
mmHg, HR 114 bpm & irregular, RR 26/min, SpO₂ 89% on 2 L NC. Chest X-ray shows
pulmonary edema; bedside echo: EF 28%, no wall-motion abnormality.
Question:
Place an X on the five most time-critical actions (within 60 min) to stabilize this patient
while minimizing harm.
Bowtie Options (select 5):
A. Hold metformin and obtain serum lactate
B. Initiate continuous furosemide infusion 5 mg/h after 40-mg IV bolus
,C. Reduce digoxin dose by 50% and check serum digoxin level
D. Start dobutamine 5 µg/kg/min
E. Switch insulin glargine to basal-bolus with 0.3 unit/kg/day and correction scale
F. Administer 15 L/min non-rebreather mask
G. Obtain renal consult for urgent dialysis planning
H. Initiate empiric ceftriaxone for HAP coverage
I. Place right-heart cath to measure PA pressures
Rationale (Revised & Verified):
● Correct Answer: A, B, D, E, G
● Analysis: 2026 AHA/ACC/HFSA guidelines prioritize perfusion assessment (A)
given marginal BP and AKI. Continuous loop diuretic (B) is superior to
intermittent bolus in diuretic-resistant HF with CKD. Dobutamine (D) is indicated
for hypoperfused HF with EF <35%. Basal-bolus insulin (E) achieves glycemic
control faster than sliding scale; metformin must be withheld due to lactic
acidosis risk. Early nephrology (G) anticipates ultrafiltration when diuresis fails or
hyperkalemia worsens.
● Distractor Breakdown: C—digoxin toxicity unlikely without neuro/visual
symptoms; holding is sufficient. F—excessive O₂ abolishes hypoxic drive in
COPD; titrate to SpO₂ 90-92%. H—no infection criteria; antibiotics promote
resistance. I—invasive monitoring is not first-hour priority.
Item ID: V3-002
Item Type: Traditional MCQ
,Scenario:
A 19-year-old primigravida at 29 weeks gestation presents with severe headache, right
upper-quadrant pain, and “spots in vision.” BP 164/108 mmHg, platelets 82 000/µL, AST
312 U/L, ALT 288 U/L, creatinine 1.3 mg/dL, 3+ proteinuria. Fetal heart tracing shows
late decelerations with minimal variability.
Question:
Which immediate intervention is most appropriate?
Options:
A. Administer betamethasone 12 mg IM and repeat in 24 h
B. Start hydralazine 5 mg IV q20min until BP <140/90 mmHg
C. Prepare for emergent cesarean delivery
D. Initiate magnesium sulfate 6 g load over 20 min
Rationale (Revised & Verified):
● Correct Answer: C
● Analysis: 2026 ACOG Practice Bulletin #222 update defines HELLP with
imminent delivery regardless of gestational age when fetal jeopardy (late
decelerations) coexists. Expectant management >34 weeks is obsolete; fetal
lung maturity is irrelevant.
● Distractor Breakdown: A—steroids are secondary once delivery timing decided.
B—BP control does not reverse placental abruption or fetal hypoxia. D—MgSO₄
prevents eclampsia but does not address fetal indication.
Item ID: V3-003
, Item Type: NGN - Matrix
Scenario:
A 54-year-old cis man with alcoholic cirrhosis (MELD-Na 24) and tense ascites is
admitted after 2-day confusion. Ammonia 142 µmol/L, INR 2.4, bilirubin 4.8 mg/dL,
creatinine 1.5 mg/dL, Na 122 mmol/L. He is oriented to person only, asterixis present.
Matrix Question:
For each intervention, indicate whether it is Contraindicated, Acceptable, or Preferred
within the first 24 h.
Intervention:
1. Lactulose 30 mL PO q2h until diarrhea
2. Rifaximin 550 mg PO BID
3. IV albumin 1.5 g/kg on day 1
4. Ceftriaxone 1 g IV daily for prophylaxis
5. Large-volume paracentesis 8 L without albumin
Rationale (Revised & Verified):
● Correct Matrix: 1-Preferred, 2-Preferred, 3-Preferred, 4-Preferred,
5-Contraindicated
● Analysis: 2026 AASLD hepatic encephalopathy guidance: lactulose titration to
2-3 soft stools/day remains first-line; rifaximin adjunct reduces recurrence.
Albumin expands plasma volume and lowers ammonia. Primary prophylaxis of
SBP with ceftriaxone is indicated when ascitic protein <1.5 g/dL and either
creatinine >1.2 or Na <130. Paracentesis >5 L mandates 6-8 g albumin per liter
removed to prevent PICD.
exam With Questions And Revised Correct Answers
& Rationales (2026/2027) 100% Guaranteed Pass
Item ID: V3-001
Item Type: NGN - Bowtie
Scenario:
A 67-year-old cisgender woman with heart-failure-reduced ejection fraction 30%, type-2
diabetes on insulin glargine 20 U hs, CKD G4 (eGFR 25 mL/min), and COPD GOLD-3 is
admitted with 3-day dyspnea, bilateral edema, and S3 gallop. Admission labs: Na 128
mmol/L, K 5.3 mmol/L, Cl 94 mmol/L, CO₂ 18 mmol/L, BUN 52 mg/dL, Scr 2.1 mg/dL,
glucose 312 mg/dL, HbA1c 9.4%. Home meds include metformin 1000 mg BID,
furosemide 80 mg PO BID, digoxin 0.25 mg daily, and tiotropium. Vital signs: BP 88/52
mmHg, HR 114 bpm & irregular, RR 26/min, SpO₂ 89% on 2 L NC. Chest X-ray shows
pulmonary edema; bedside echo: EF 28%, no wall-motion abnormality.
Question:
Place an X on the five most time-critical actions (within 60 min) to stabilize this patient
while minimizing harm.
Bowtie Options (select 5):
A. Hold metformin and obtain serum lactate
B. Initiate continuous furosemide infusion 5 mg/h after 40-mg IV bolus
,C. Reduce digoxin dose by 50% and check serum digoxin level
D. Start dobutamine 5 µg/kg/min
E. Switch insulin glargine to basal-bolus with 0.3 unit/kg/day and correction scale
F. Administer 15 L/min non-rebreather mask
G. Obtain renal consult for urgent dialysis planning
H. Initiate empiric ceftriaxone for HAP coverage
I. Place right-heart cath to measure PA pressures
Rationale (Revised & Verified):
● Correct Answer: A, B, D, E, G
● Analysis: 2026 AHA/ACC/HFSA guidelines prioritize perfusion assessment (A)
given marginal BP and AKI. Continuous loop diuretic (B) is superior to
intermittent bolus in diuretic-resistant HF with CKD. Dobutamine (D) is indicated
for hypoperfused HF with EF <35%. Basal-bolus insulin (E) achieves glycemic
control faster than sliding scale; metformin must be withheld due to lactic
acidosis risk. Early nephrology (G) anticipates ultrafiltration when diuresis fails or
hyperkalemia worsens.
● Distractor Breakdown: C—digoxin toxicity unlikely without neuro/visual
symptoms; holding is sufficient. F—excessive O₂ abolishes hypoxic drive in
COPD; titrate to SpO₂ 90-92%. H—no infection criteria; antibiotics promote
resistance. I—invasive monitoring is not first-hour priority.
Item ID: V3-002
Item Type: Traditional MCQ
,Scenario:
A 19-year-old primigravida at 29 weeks gestation presents with severe headache, right
upper-quadrant pain, and “spots in vision.” BP 164/108 mmHg, platelets 82 000/µL, AST
312 U/L, ALT 288 U/L, creatinine 1.3 mg/dL, 3+ proteinuria. Fetal heart tracing shows
late decelerations with minimal variability.
Question:
Which immediate intervention is most appropriate?
Options:
A. Administer betamethasone 12 mg IM and repeat in 24 h
B. Start hydralazine 5 mg IV q20min until BP <140/90 mmHg
C. Prepare for emergent cesarean delivery
D. Initiate magnesium sulfate 6 g load over 20 min
Rationale (Revised & Verified):
● Correct Answer: C
● Analysis: 2026 ACOG Practice Bulletin #222 update defines HELLP with
imminent delivery regardless of gestational age when fetal jeopardy (late
decelerations) coexists. Expectant management >34 weeks is obsolete; fetal
lung maturity is irrelevant.
● Distractor Breakdown: A—steroids are secondary once delivery timing decided.
B—BP control does not reverse placental abruption or fetal hypoxia. D—MgSO₄
prevents eclampsia but does not address fetal indication.
Item ID: V3-003
, Item Type: NGN - Matrix
Scenario:
A 54-year-old cis man with alcoholic cirrhosis (MELD-Na 24) and tense ascites is
admitted after 2-day confusion. Ammonia 142 µmol/L, INR 2.4, bilirubin 4.8 mg/dL,
creatinine 1.5 mg/dL, Na 122 mmol/L. He is oriented to person only, asterixis present.
Matrix Question:
For each intervention, indicate whether it is Contraindicated, Acceptable, or Preferred
within the first 24 h.
Intervention:
1. Lactulose 30 mL PO q2h until diarrhea
2. Rifaximin 550 mg PO BID
3. IV albumin 1.5 g/kg on day 1
4. Ceftriaxone 1 g IV daily for prophylaxis
5. Large-volume paracentesis 8 L without albumin
Rationale (Revised & Verified):
● Correct Matrix: 1-Preferred, 2-Preferred, 3-Preferred, 4-Preferred,
5-Contraindicated
● Analysis: 2026 AASLD hepatic encephalopathy guidance: lactulose titration to
2-3 soft stools/day remains first-line; rifaximin adjunct reduces recurrence.
Albumin expands plasma volume and lowers ammonia. Primary prophylaxis of
SBP with ceftriaxone is indicated when ascitic protein <1.5 g/dL and either
creatinine >1.2 or Na <130. Paracentesis >5 L mandates 6-8 g albumin per liter
removed to prevent PICD.
