ATI NCLEX Practice
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During a home health assessment the nurse witnesses a school age child fall from a
second story window. Which is the priority action? - -Tell the child not to move
*Do not rule out spinal cord injury*
✅✅
A unit manager observes several nurses working throughout the day.. Which action
represents a breach in client confidentiality ? - -Posting positive information
about a client on social media website.
✅✅
A client who is newly admitted requests information about advanced directives. The
nurse should include which of the following statements in discussion ? - -I will
give you a pamphlet with written information about advanced directives.
✅✅
A nurse completes a home health assessment on an older adult who has a broken
arm and burns to the chest. Which action is needed at this time? - -Contact
adult protective services.
✅✅
A client arrives to the ED and reports HA, neck stiffness and sensitivity to light.
Which is the priority nursing action? - -Implement droplet precautions- possible
meningitis (highly contagious if bacterial)
A bladder irrigation is prescribed for a client who has an occluded indwelling cath.
✅✅
Which action should nurse take when unsure of how to perform this procedure? -
-Refer to the policy and procedure manual
✅✅
A charge nurse reviews abbreviations in client documentation. Which is an approved
entry? - -Furosemide 60 mg PO daily
A nurse participates in quality improvement to decrease hospital readmissions for
✅✅
clients who have heart failure. .Which action should the nurse expect to perform? -
-Compare performance to current practice standards
✅✅
A nurse assigns care for client who has DM to an LPN and a UAP. Which task
should be given to the LPN? - -Obtain capillary glucose
✅✅
A client with a stage IV pancreatic cancer decides to DC all treatment. Which action
should the nurse take? - -Ask client to discuss decision
✅✅
A nurse receives a client's medication over the telephone from the provider. Which
action should the nurse take? - -Repeat the prescription back to the provider
, ✅✅
A nurse receives end of shift report. Which of the following client assessment
findings should nurse address first ? - -New onset of confusion in client with L
femur fracture ( Fat emboli risk/ Hypoxia)
A nurse should notify public health about which infections? - ✅✅--gonorrhea
-hep C
-Chlamydia
-Meningococcal
✅✅
A client with a new diagnosis of stage IV lung cancer, when partner requests the dx
be withheld from the client, which action should the nurse take ? - -Request
additional information from partner
✅✅
A nurse reviews the plan of care for client who has myasthenia gravis. Which
intervention requires a revision? - -Assist with daily activities prior to medication
admin
✅✅
A client who has COPD is prescribed ipatropium. The nurse should instruct the client
to report which sx immediately ? - -Eye pain
An older adult client who is receiving a blood transfusion develops an increased BP
✅✅
and crackles bilaterally. Which medication should nurse administer? -
-Furosemide ( fluid overload)
✅✅
A nurse provides teaching to a client who is prescribed spironolactone. Nurse should
limit the intake of which foods? - -Bananas
Tomatoes
Avocados
Sweet potatoes
✅✅
A client is prescribed acetaminophen 650 mg PO every 4 hours PRN. which finding
should alert the nurse to question this prescription ? - -reports drinking 6 beers
daily
A school age child with ADHD is observed having increased concentration and ability
✅✅
to complete tasks. Nurse recognizes which medication may contribute to this? -
-Methylphenidate
✅✅
An unresponsive client is brought in with a RR of 8 with pinpoint pupils. Which med
should be given? - -Naloxone
✅✅
A nurse providing discharge instructions to a client who is newly prescribed lisinopril.
Which statement indicates teaching was effective? - --it is an emergency if
mouth begins to swell
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