ATI NCLEX Questions And Answers 100% Verified.
A client is exhibiting early signs of hemorrhage. Which findings should the nurse anticipate?
1. Cold, clammy skin
2. Heart rate 120/min
3. Weak, thready pulse
4. Blood pressure 80/60 - correct answer. 2. Heart rate 120/min
An ol...
A client is exhibiting early signs of hemorrhage. Which findings should the nurse
anticipate?
1. Cold, clammy skin
2. Heart rate 120/min
3. Weak, thready pulse
4. Blood pressure 80/60 - correct answer. 2. Heart rate 120/min
An older adult client reports recurring calf pain after walking one to two blocks that
disappears with rest. The client has weak pedal pulses, and skin on the left lower leg is
shiny and cool to the touch. Which nursing intervention is appropriate at this time?
1. Position the left leg dependently
2. Elevate the left leg above the heart
3. Immobilize the left leg to prevent further injury
4. Assess dorsiflexion and extension of the left foot - correct answer. 1. Position the
left leg dependently
A client who has just been diagnosed with rheumatoid arthritis is required to receive 3
months of methotrexate therapy. The nurse recognizes which of the following are
adverse effects associated with the therapy? SATA
1. WBC 1,200
2. Weight gain 2.27 kg (5 lbs.)
3. Oral temperature of 37.2 (99)
4. Urine Specific Gravity 1.003
5. Platelets 5,000 - correct answer. 1. WBC 1,200
5. Platelets 5,000
A nurse prepares a staff in-service on incident reports. Which information should the
nurse include? SATA
1. Risk management investigates the incident
2. A copy of report is placed in client's health record
,3. Reports include description of incident and actions taken
4. Reports are confidential and not shared with noninvolved staff
5. Completion of report should be documented in the nurses' notes - correct answer.
1. Risk management investigates the incident
3. Reports include description of incident and actions taken
4. Reports are confidential and not shared with noninvolved staff
A nurse is unsure of the proper technique when caring for a client who is prescribes
enteral feedings. Which action should the nurse take?
1. Ask the charge nurse for step-by-step directions
2. Call the provider for specific instructions
3. Consult the unit procedure manual for guidance
4. Delegate task to a LPN to complete the feedings. - correct answer. 3. Consult the
unit procedure manual for guidance
A nurse admits a client from a long-term care facility. Which action should be
implemented? SATA
1. Verify the admission medications prescribed by the provider
2. Review the current medication regimen with the client
3. Obtain the most recent list of mediations from the long-term care facility
4. Locate a list of discharge medications from the most recent hospitalization.
5. Discuss any discrepancies with the health care provider - correct answer. 1. Verify
the admission medications prescribed by the provider
2. Review the current medication regimen with the client
3. Obtain the most recent list of medications from the long-term care facility
5. discuss any discrepancies with the health care provider
A nurse cares for a client with terminal lung cancer. Which action should be delegated
to the UAP? SATA
1. Encourage client to express feelings about the terminal diagnosis
2. Assist the client to ambulate to the bedside chair twice a day
3. Demonstrate to client the proper use of a bronchodilator inhaler
4. Complete vital signs that include oxygen saturation every 4 hours
5. Obtain a urine specimen from the client's indwelling bladder catheter - correct
answer. 2. Assist the client to ambulate to the bedside chair twice a day
4. Complete vital signs that include oxygen saturation every 4 hours
A nurse cares for a group of clients on a med-surg unit. Which client should be
delegated to the LPN? SATA. A client with
1. Newly diagnosed DM2
2. Facial lacerations and a subdural hematoma
3. Bronchitis receiving bronchodilator treatments
4. Exacerbation of myasthenia gravis admitted three hours ago
5. Advanced regular diet two days post chole - correct answer. 3. Bronchitis receiving
bronchodilator treatments
5. Advanced regular diet two days post chole
,A nurse enters the room of a client who is at the foot of the bed lying on the floor. Which
should be the initial nursing action?
1. Examine the client for injuries
2. Obtain HR and BP
3. Assess vital signs and LOC
4. Determine intensity of pain with ROM - correct answer. 3. Assess vital signs and
LOC
Four days after a ventral hernia repair, a client who is obese and has a history of COPD
vomits and reports severe abdominal pain. The oxygen saturation is 90%. Which action
should the nurse implement first?
1. Administer ondansetron hcl IV
2. Encourage pursed lip breathing
3. Assess the surgical incision site
4. Apply low dose oxygen via nasal cannula - correct answer. 3. Assess the surgical
incision site
A nurse arrives at a work site explosion. Which client should be triaged first? A client
who has
1. Fixed pupils an agonal respirations
2. Burns to the face and respiratory stridor
3. Type 2 DM who is disoriented
4. A closed fracture reporting "a pain level of 3" - correct answer. 2. Burns to the face
and respiratory stridor
A home health nurse is performing an admission assessment on a client who has a
knee arthroplasty one week ago. Which client statement should concern the nurse the
most?
1. "I am so glad to be of those blood thinners"
2. "I will keep a pillow under my knee when I am in bed"
3. "I am planning to use a wheelchair to help me get around"
4. "I plan to take ibuprofen instead of the prescribed hydrocodone with acetaminophen
for pain control" - correct answer. 1. "I am so glad to be of those blood thinners"
A nurse provides care for a client who has a chest tube. The nurse notes the chest tube
has become disconnected from the chest drainage system. Which action should the
nurse take?
1. Increase suction to the chest drainage system.
2. Reposition the client to a high-fowler's position
3. Apply to the client low-flow oxygen via nasal cannula
4. Immerse the end of the chest tube in a bottle of sterile water - correct answer. 4.
Immerse the end of the chest tube in a bottle of sterile water
A client receives a transfusion of packed RBC's and tells the nurse "My IV site is painful
and looks like it is swollen" Which action should the nurse take?
, 1. Continue to monitor the site for signs of infection or infiltration
2. Double check the blood type of the unit of blood with another nurse
3. Start a new IV at another site and resume the transfusion at the new site
4. Discontinue the transfusion and send the remaining blood and tubing to the lab -
correct answer. 3. Start a new IV at another site and resume the transfusion at the new
site
A client who has recently undergone surgery for a tracheostomy is now at home. The
nurse recognizes a need for immediate intervention when the caregiver does which of
the following?
1. Suctions intermittently for 15 seconds
2. Places an air humidifier at the bedside
3. Cuts a 4x4 gauze to put around the tracheostomy tube
4. Removes the ties before cleaning the tracheostomy - correct answer. 4. Removes
the ties before cleaning the tracheostomy
A nurse assigns four clients to the LPN. Which finding should the LPN immediately
report to the nurse? A client
1. Receiving long-term IV abx who has a rash in his left groin
2. with baseline regular apical pulse of 88 who has an irregular apical pulse of 120
today
3. Who has a recent diagnosis of terminal cancer and refuses to eat or participate in
hygiene care.
4. eight hours post laparoscopic surgery who reports abdominal distention and shoulder
pain. - correct answer. 2. with baseline regular apical pulse of 88 who has an irregular
apical pulse of 120 today
A nurse plans to administer the following medication. Which medication should the
nurse administer first?
1. A scheduled IV abx for a client with resolving pneumonia.
2. Pain medication to a client who rates their pain a 4-5 on a 0-10 scale
3. An antidiarrheal for a client with one diarrhea stool in the last hour
4. The antipyretic to a client with a temperature of 100.7 (38.2) - correct answer. 1. A
scheduled IV abx for a client with resolving pneumonia.
A nurse cares for a group of clients. Which information can be disclosed about a client?
1. HIV status to the client's coworkers
2. Stage IV cancer diagnosis to the client's family
3. Uncontrolled seizure disorder to DMV
4. Alcohol detoxification recovery status to client's employer - correct answer. 3.
Uncontrolled seizure disorder to DMV
A nurse notes the 16-year old signed the consent form for a surgical procedure. Which
action should be first?
1. Cancel the surgical procedure until a valid consent form can be signed.
2. Verify the signature is witnessed appropriately and send the client for the surgery.
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