ATI RN CompReheNsIve pRedICToR NGN
pRACTICe exAm (120 QuesTIoNs) QuesTIoN ANd
ANsWeRs ALReAdY GRAded A+
Question 1
A nurse is caring for a client who has acute respiratory distress. Which assessment finding
requires immediate intervention?
A. Respiratory rate 24/min
B. Oxygen saturation 84% on room air
C. Heart rate 102/min
D. Temperature 37.8°C (100°F)
Answer: B
Rationale: An oxygen saturation of 84% indicates significant hypoxemia. According to ABC
priorities, airway and breathing concerns take precedence over all other findings.
Question 2
A nurse is assessing a client who has heart failure. Which finding indicates fluid volume excess?
A. Weight loss of 1 kg
B. Dry mucous membranes
C. Crackles in lung bases
D. Decreased blood pressure
Answer: C
Rationale: Crackles indicate pulmonary fluid accumulation, a hallmark of heart failure
exacerbation.
Question 3
,A nurse is preparing to administer digoxin. Which finding should cause the nurse to withhold
the medication?
A. Respiratory rate 18/min
B. Apical pulse 54/min
C. Blood pressure 138/80 mm Hg
D. Temperature 37°C
Answer: B
Rationale: Digoxin should generally be withheld if the apical pulse is below 60/min because it
can further decrease heart rate.
Question 4
A nurse is caring for a client who is experiencing hypoglycemia. Which finding should the nurse
expect?
A. Warm dry skin
B. Bradycardia
C. Diaphoresis
D. Hypertension
Answer: C
Rationale: Hypoglycemia stimulates the sympathetic nervous system, resulting in diaphoresis,
shakiness, and tachycardia.
Question 5
A nurse is caring for a client who has bacterial meningitis. Which isolation precaution should be
implemented?
A. Airborne
B. Contact
C. Droplet
D. Protective
Answer: C
Rationale: Bacterial meningitis is spread through respiratory droplets and requires droplet
precautions.
,Question 6
Which client should the nurse assess first?
A. Client with chronic back pain requesting medication
B. Client with new onset chest pain
C. Client awaiting discharge instructions
D. Client requesting assistance to the bathroom
Answer: B
Rationale: Chest pain may indicate myocardial ischemia and requires immediate assessment.
Question 7
A nurse is caring for a client following thyroidectomy. Which finding requires immediate action?
A. Hoarseness
B. Pain level 4/10
C. Temperature 37.4°C
D. Incision drainage scant
Answer: A
Rationale: Hoarseness may indicate laryngeal nerve damage or airway compromise.
Question 8
A client has a potassium level of 2.9 mEq/L. Which assessment finding is expected?
A. Muscle weakness
B. Hyperactive reflexes
C. Bradycardia
D. Constipation absent
Answer: A
Rationale: Hypokalemia commonly causes muscle weakness and cardiac dysrhythmias.
Question 9
, A nurse is caring for a client receiving heparin. Which laboratory value should be monitored?
A. INR
B. PT
C. aPTT
D. Hemoglobin A1C
Answer: C
Rationale: aPTT is used to monitor therapeutic heparin therapy.
Question 10
Which statement by a client taking warfarin indicates understanding?
A. "I will take aspirin for headaches."
B. "I will use a soft toothbrush."
C. "I can stop the medication when I feel better."
D. "I should increase vitamin K intake."
Answer: B
Rationale: Soft toothbrushes reduce bleeding risk while taking anticoagulants.
Question 11
A nurse is caring for a client with COPD. Which oxygen delivery method is most appropriate?
A. Nonrebreather mask at 15 L/min
B. Nasal cannula at low flow
C. Venturi mask 100%
D. Face tent
Answer: B
Rationale: COPD clients often require low-flow oxygen to prevent suppression of respiratory
drive.
Question 12
A client develops sudden unilateral weakness and slurred speech. What is the priority action?
pRACTICe exAm (120 QuesTIoNs) QuesTIoN ANd
ANsWeRs ALReAdY GRAded A+
Question 1
A nurse is caring for a client who has acute respiratory distress. Which assessment finding
requires immediate intervention?
A. Respiratory rate 24/min
B. Oxygen saturation 84% on room air
C. Heart rate 102/min
D. Temperature 37.8°C (100°F)
Answer: B
Rationale: An oxygen saturation of 84% indicates significant hypoxemia. According to ABC
priorities, airway and breathing concerns take precedence over all other findings.
Question 2
A nurse is assessing a client who has heart failure. Which finding indicates fluid volume excess?
A. Weight loss of 1 kg
B. Dry mucous membranes
C. Crackles in lung bases
D. Decreased blood pressure
Answer: C
Rationale: Crackles indicate pulmonary fluid accumulation, a hallmark of heart failure
exacerbation.
Question 3
,A nurse is preparing to administer digoxin. Which finding should cause the nurse to withhold
the medication?
A. Respiratory rate 18/min
B. Apical pulse 54/min
C. Blood pressure 138/80 mm Hg
D. Temperature 37°C
Answer: B
Rationale: Digoxin should generally be withheld if the apical pulse is below 60/min because it
can further decrease heart rate.
Question 4
A nurse is caring for a client who is experiencing hypoglycemia. Which finding should the nurse
expect?
A. Warm dry skin
B. Bradycardia
C. Diaphoresis
D. Hypertension
Answer: C
Rationale: Hypoglycemia stimulates the sympathetic nervous system, resulting in diaphoresis,
shakiness, and tachycardia.
Question 5
A nurse is caring for a client who has bacterial meningitis. Which isolation precaution should be
implemented?
A. Airborne
B. Contact
C. Droplet
D. Protective
Answer: C
Rationale: Bacterial meningitis is spread through respiratory droplets and requires droplet
precautions.
,Question 6
Which client should the nurse assess first?
A. Client with chronic back pain requesting medication
B. Client with new onset chest pain
C. Client awaiting discharge instructions
D. Client requesting assistance to the bathroom
Answer: B
Rationale: Chest pain may indicate myocardial ischemia and requires immediate assessment.
Question 7
A nurse is caring for a client following thyroidectomy. Which finding requires immediate action?
A. Hoarseness
B. Pain level 4/10
C. Temperature 37.4°C
D. Incision drainage scant
Answer: A
Rationale: Hoarseness may indicate laryngeal nerve damage or airway compromise.
Question 8
A client has a potassium level of 2.9 mEq/L. Which assessment finding is expected?
A. Muscle weakness
B. Hyperactive reflexes
C. Bradycardia
D. Constipation absent
Answer: A
Rationale: Hypokalemia commonly causes muscle weakness and cardiac dysrhythmias.
Question 9
, A nurse is caring for a client receiving heparin. Which laboratory value should be monitored?
A. INR
B. PT
C. aPTT
D. Hemoglobin A1C
Answer: C
Rationale: aPTT is used to monitor therapeutic heparin therapy.
Question 10
Which statement by a client taking warfarin indicates understanding?
A. "I will take aspirin for headaches."
B. "I will use a soft toothbrush."
C. "I can stop the medication when I feel better."
D. "I should increase vitamin K intake."
Answer: B
Rationale: Soft toothbrushes reduce bleeding risk while taking anticoagulants.
Question 11
A nurse is caring for a client with COPD. Which oxygen delivery method is most appropriate?
A. Nonrebreather mask at 15 L/min
B. Nasal cannula at low flow
C. Venturi mask 100%
D. Face tent
Answer: B
Rationale: COPD clients often require low-flow oxygen to prevent suppression of respiratory
drive.
Question 12
A client develops sudden unilateral weakness and slurred speech. What is the priority action?
