ATI RN Adult Medical‑Surgical NGN
2026–2027| Questions and Answers |
Verified Complete Solutions | Nursing
Clinical Judgment Study Guide
(2026–2027)
1. A nurse is delegating client care on a busy medical-surgical unit. Which of the following
clients is appropriate to assign to an unlicensed assistive personnel (UAP) for
ambulation?
A. A client who is 1 day postoperative following a total knee arthroplasty and has an
active prescription for low-molecular-weight heparin for deep vein thrombosis
prophylaxis
B. A client who is 3 days postoperative following an appendectomy, has a steady gait,
and vital signs within normal limits
C. A client with a chest tube following a thoracotomy who requires frequent turning
D. A client who had a recent cerebrovascular accident with left-sided weakness
Answer: B. Unlicensed assistive personnel can safely ambulate stable postoperative
clients without complications or acute risks, as this task involves basic activities of daily
living and does not require assessment or clinical judgment.
2. A nurse is caring for a client who has a chronic obstructive pulmonary disease (COPD)
exacerbation with arterial blood gas results showing pH 7.32, PaCO2 55 mm Hg, PaO2
60 mm Hg, and HCO3- 28 mEq/L. Which of the following interventions should the nurse
implement first?
A. Administer albuterol via nebulizer
B. Initiate bilevel positive airway pressure (BiPAP) ventilation
C. Encourage the client to cough and deep breathe
D. Administer intravenous fluids at 125 mL/hr
Answer: B. The findings indicate acute respiratory acidosis due to CO2 retention from
hypoventilation; BiPAP provides noninvasive ventilatory support to improve gas
exchange and correct acid-base imbalance before bronchodilators or other measures.
3. A nurse is preparing to administer a high-alert medication and scans the barcode, which
does not match the client's wristband. Which of the following actions should the nurse
take first?
A. Return the medication to the automated dispensing cabinet
B. Administer the medication and document the discrepancy
C. Ask the UAP to verify the client's identity
, D. Notify the charge nurse after administration
Answer: A. Barcode scanning is a critical patient safety measure to prevent
wrong-patient medication errors; returning the medication ensures verification and
prevents harm.
4. A nurse is assessing a client who reports substernal chest pain radiating to the jaw,
diaphoresis, and nausea. The client's 12-lead electrocardiogram shows sinus
tachycardia with no ST-segment changes. Which of the following actions should the
nurse take first?
A. Administer oxygen at 2 L/min via nasal cannula
B. Obtain serum troponin levels
C. Administer aspirin 325 mg orally
D. Prepare for percutaneous coronary intervention
Answer: A. Oxygenation supports myocardial oxygen demand and is the initial priority
action for suspected acute coronary syndrome per American Heart Association
guidelines, regardless of ECG findings.
5. A nurse is delegating care for a client who has stable chronic heart failure with ejection
fraction 45% and is receiving furosemide 40 mg daily. Which of the following tasks is
appropriate to delegate to a licensed practical nurse (LPN)?
A. Performing the initial head-to-toe assessment
B. Obtaining and recording daily weight
C. Evaluating the client's response to the morning diuretic dose
D. Developing a low-sodium diet teaching plan
Answer: B. Licensed practical nurses can perform data collection tasks such as daily
weights for stable clients with chronic conditions; assessment, evaluation, and teaching
require registered nurse scope of practice.
6. A nurse notes 300 mL of bright green bilious output from a client's newly inserted
percutaneous endoscopic gastrostomy (PEG) tube 2 hours after placement. Which of the
following actions should the nurse take first?
A. Notify the provider immediately
B. Reposition the client to the left side
C. Clamp the tube for 1 hour
D. Irrigate the tube with 30 mL of water
Answer: A. Excessive bilious output suggests possible gastric displacement,
perforation, or leakage, requiring urgent provider evaluation to prevent peritonitis or
other complications.
7. A nurse is using the ABC (airway, breathing, circulation) framework to prioritize
assessments for four clients on the medical-surgical unit. Which of the following clients
should the nurse assess first?
A. An alert client with a blood glucose of 55 mg/dL requesting insulin teaching
B. A client who is choking on food and cannot speak or cough
C. A client with a temperature of 38.5°C (101.3°F) and chills
D. A client reporting severe pain from a fractured arm
Answer: B. Complete airway obstruction is an immediate life-threatening emergency
, requiring the Heimlich maneuver or emergency response before addressing other
physiological needs.
8. A nurse is leading a code blue response for a client in cardiac arrest with pulseless
ventricular tachycardia. Which of the following tasks should the nurse delegate first to
the unlicensed assistive personnel on the team?
A. Perform continuous chest compressions at 100 to 120/min
B. Manage the advanced airway
C. Analyze the rhythm on the defibrillator
D. Administer epinephrine 1 mg IV
Answer: A. Unlicensed assistive personnel are trained to provide high-quality chest
compressions during resuscitation, allowing the registered nurse to focus on rhythm
analysis and defibrillation.
9. A nurse is reviewing laboratory results for a client receiving warfarin therapy for atrial
fibrillation, which reveal an international normalized ratio (INR) of 4.5. Which of the
following actions should the nurse take first?
A. Withhold the next dose of warfarin
B. Administer phytonadione (vitamin K) 2.5 mg orally
C. Continue the warfarin as prescribed
D. Increase the warfarin dose to reverse the INR
Answer: A. An INR above the therapeutic range of 2 to 3 increases bleeding risk;
withholding the next dose and notifying the provider is the initial action to prevent
hemorrhage.
10.A nurse is assessing a client experiencing acute respiratory distress with a respiratory
rate of 36/min, use of accessory muscles, and SpO2 86% on room air. Which of the
following interventions should the nurse implement first?
A. Apply a nonrebreather mask at 15 L/min
B. Prepare the client for endotracheal intubation
C. Obtain a portable chest x-ray
D. Administer broad-spectrum antibiotics intravenously
Answer: A. High-flow oxygen delivery is the priority to correct hypoxemia and stabilize
breathing before diagnostic tests or advanced airway management.
11.During hourly safety rounding, a nurse finds a client on fall precautions attempting to
climb over the bedrails. Which of the following nonrestraint interventions should the
nurse implement first?
A. Lower all four side rails and activate the bed alarm
B. Apply bilateral soft wrist restraints
C. Delegate continuous supervision to the UAP
D. Administer a sedative medication
Answer: A. Environmental modifications such as lowering the bed and using alarms
address fall risk while adhering to least-restrictive principles and promoting patient
dignity.
12.A nurse is monitoring a client admitted with acute kidney injury who has a urine output of
20 mL/hr for the past 4 hours. Which of the following laboratory tests should the nurse
review first?
2026–2027| Questions and Answers |
Verified Complete Solutions | Nursing
Clinical Judgment Study Guide
(2026–2027)
1. A nurse is delegating client care on a busy medical-surgical unit. Which of the following
clients is appropriate to assign to an unlicensed assistive personnel (UAP) for
ambulation?
A. A client who is 1 day postoperative following a total knee arthroplasty and has an
active prescription for low-molecular-weight heparin for deep vein thrombosis
prophylaxis
B. A client who is 3 days postoperative following an appendectomy, has a steady gait,
and vital signs within normal limits
C. A client with a chest tube following a thoracotomy who requires frequent turning
D. A client who had a recent cerebrovascular accident with left-sided weakness
Answer: B. Unlicensed assistive personnel can safely ambulate stable postoperative
clients without complications or acute risks, as this task involves basic activities of daily
living and does not require assessment or clinical judgment.
2. A nurse is caring for a client who has a chronic obstructive pulmonary disease (COPD)
exacerbation with arterial blood gas results showing pH 7.32, PaCO2 55 mm Hg, PaO2
60 mm Hg, and HCO3- 28 mEq/L. Which of the following interventions should the nurse
implement first?
A. Administer albuterol via nebulizer
B. Initiate bilevel positive airway pressure (BiPAP) ventilation
C. Encourage the client to cough and deep breathe
D. Administer intravenous fluids at 125 mL/hr
Answer: B. The findings indicate acute respiratory acidosis due to CO2 retention from
hypoventilation; BiPAP provides noninvasive ventilatory support to improve gas
exchange and correct acid-base imbalance before bronchodilators or other measures.
3. A nurse is preparing to administer a high-alert medication and scans the barcode, which
does not match the client's wristband. Which of the following actions should the nurse
take first?
A. Return the medication to the automated dispensing cabinet
B. Administer the medication and document the discrepancy
C. Ask the UAP to verify the client's identity
, D. Notify the charge nurse after administration
Answer: A. Barcode scanning is a critical patient safety measure to prevent
wrong-patient medication errors; returning the medication ensures verification and
prevents harm.
4. A nurse is assessing a client who reports substernal chest pain radiating to the jaw,
diaphoresis, and nausea. The client's 12-lead electrocardiogram shows sinus
tachycardia with no ST-segment changes. Which of the following actions should the
nurse take first?
A. Administer oxygen at 2 L/min via nasal cannula
B. Obtain serum troponin levels
C. Administer aspirin 325 mg orally
D. Prepare for percutaneous coronary intervention
Answer: A. Oxygenation supports myocardial oxygen demand and is the initial priority
action for suspected acute coronary syndrome per American Heart Association
guidelines, regardless of ECG findings.
5. A nurse is delegating care for a client who has stable chronic heart failure with ejection
fraction 45% and is receiving furosemide 40 mg daily. Which of the following tasks is
appropriate to delegate to a licensed practical nurse (LPN)?
A. Performing the initial head-to-toe assessment
B. Obtaining and recording daily weight
C. Evaluating the client's response to the morning diuretic dose
D. Developing a low-sodium diet teaching plan
Answer: B. Licensed practical nurses can perform data collection tasks such as daily
weights for stable clients with chronic conditions; assessment, evaluation, and teaching
require registered nurse scope of practice.
6. A nurse notes 300 mL of bright green bilious output from a client's newly inserted
percutaneous endoscopic gastrostomy (PEG) tube 2 hours after placement. Which of the
following actions should the nurse take first?
A. Notify the provider immediately
B. Reposition the client to the left side
C. Clamp the tube for 1 hour
D. Irrigate the tube with 30 mL of water
Answer: A. Excessive bilious output suggests possible gastric displacement,
perforation, or leakage, requiring urgent provider evaluation to prevent peritonitis or
other complications.
7. A nurse is using the ABC (airway, breathing, circulation) framework to prioritize
assessments for four clients on the medical-surgical unit. Which of the following clients
should the nurse assess first?
A. An alert client with a blood glucose of 55 mg/dL requesting insulin teaching
B. A client who is choking on food and cannot speak or cough
C. A client with a temperature of 38.5°C (101.3°F) and chills
D. A client reporting severe pain from a fractured arm
Answer: B. Complete airway obstruction is an immediate life-threatening emergency
, requiring the Heimlich maneuver or emergency response before addressing other
physiological needs.
8. A nurse is leading a code blue response for a client in cardiac arrest with pulseless
ventricular tachycardia. Which of the following tasks should the nurse delegate first to
the unlicensed assistive personnel on the team?
A. Perform continuous chest compressions at 100 to 120/min
B. Manage the advanced airway
C. Analyze the rhythm on the defibrillator
D. Administer epinephrine 1 mg IV
Answer: A. Unlicensed assistive personnel are trained to provide high-quality chest
compressions during resuscitation, allowing the registered nurse to focus on rhythm
analysis and defibrillation.
9. A nurse is reviewing laboratory results for a client receiving warfarin therapy for atrial
fibrillation, which reveal an international normalized ratio (INR) of 4.5. Which of the
following actions should the nurse take first?
A. Withhold the next dose of warfarin
B. Administer phytonadione (vitamin K) 2.5 mg orally
C. Continue the warfarin as prescribed
D. Increase the warfarin dose to reverse the INR
Answer: A. An INR above the therapeutic range of 2 to 3 increases bleeding risk;
withholding the next dose and notifying the provider is the initial action to prevent
hemorrhage.
10.A nurse is assessing a client experiencing acute respiratory distress with a respiratory
rate of 36/min, use of accessory muscles, and SpO2 86% on room air. Which of the
following interventions should the nurse implement first?
A. Apply a nonrebreather mask at 15 L/min
B. Prepare the client for endotracheal intubation
C. Obtain a portable chest x-ray
D. Administer broad-spectrum antibiotics intravenously
Answer: A. High-flow oxygen delivery is the priority to correct hypoxemia and stabilize
breathing before diagnostic tests or advanced airway management.
11.During hourly safety rounding, a nurse finds a client on fall precautions attempting to
climb over the bedrails. Which of the following nonrestraint interventions should the
nurse implement first?
A. Lower all four side rails and activate the bed alarm
B. Apply bilateral soft wrist restraints
C. Delegate continuous supervision to the UAP
D. Administer a sedative medication
Answer: A. Environmental modifications such as lowering the bed and using alarms
address fall risk while adhering to least-restrictive principles and promoting patient
dignity.
12.A nurse is monitoring a client admitted with acute kidney injury who has a urine output of
20 mL/hr for the past 4 hours. Which of the following laboratory tests should the nurse
review first?
