ATI NCLEX Questions and Answers Graded A+
A client is exhibiting early signs of hemorrhage. Which
findings should the nurse anticipate?
1. Cold, clammy skin
2. Heart rate 120/min
2. Heart rate 120/min
3. Weak, thready pulse
4. Blood pressure 80/60
An older adult client reports recurring calf pain after walk-
ing 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
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
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 ettects associated with the therapy? SATA
1. WBC 1,200
1. WBC 1,200
5. Platelets 5,000
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
A nurse prepares a statt in-service on incident reports.
Which information should the nurse include? SATA
1. Risk management investigates the incident
1. Risk management investigates the incident
3. Reports include description of incident and actions tak-
2. A copy of report is placed in client's health record
en
3. Reports include description of incident and actions
taken
, ATI NCLEX Questions and Answers Graded A+
4. Reports are confidential and not shared with nonin-
volved statt 4. Reports are confidential and not shared with nonin-
5. Completion of report should be documented in the volved statt
nurses' notes
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 3. Consult the unit procedure manual for guidance
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.
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 1. Verify the admission medications prescribed by the
provider provider
2. Review the current medication regimen with the client 2. Review the current medication regimen with the client
3. Obtain the most recent list of mediations from the 3. Obtain the most recent list of medications from the
long-term care facility long-term care facility
4. Locate a list of discharge medications from the most 5. discuss any discrepancies with the health care provider
recent hospitalization.
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
2. Assist the client to ambulate to the bedside chair twice a day
a day 4. Complete vital signs that include oxygen saturation
3. Demonstrate to client the proper use of a bronchodila- every 4 hours
tor inhaler
4. Complete vital signs that include oxygen saturation
every 4 hours
, ATI NCLEX Questions and Answers Graded A+
5. Obtain a urine specimen from the client's indwelling
bladder catheter
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
3. Bronchitis receiving bronchodilator treatments
2. Facial lacerations and a subdural hematoma
5. Advanced regular diet two days post chole
3. Bronchitis receiving bronchodilator treatments
4. Exacerbation of myasthenia gravis admitted three hours
ago
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 3. Assess vital signs and LOC
2. Obtain HR and BP
3. Assess vital signs and LOC
4. Determine intensity of pain with ROM
Four days after a ventral hernia repair, a client who is
obese and has a history of COPD vomits and reports se-
vere abdominal pain. The oxygen saturation is 90%. Which
action should the nurse implement first?
3. Assess the surgical incision site
1. Administer ondansetron hcl IV
2. Encourage pursed lip breathing
3. Assess the surgical incision site
4. Apply low dose oxygen via nasal cannula
A nurse arrives at a work site explosion. Which client
should be triaged first? A client who has
2. Burns to the face and respiratory stridor
1. Fixed pupils an agonal respirations
2. Burns to the face and respiratory stridor
, ATI NCLEX Questions and Answers Graded A+
3. Type 2 DM who is disoriented
4. A closed fracture reporting "a pain level of 3"
A home health nurse is performing an admission assess-
ment 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"
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"
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?
4. Immerse the end of the chest tube in a bottle of sterile
1. Increase suction to the chest drainage system.
water
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
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
3. Start a new IV at another site and resume the transfusion
infiltration
at the new site
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 transfu-
sion at the new site
A client is exhibiting early signs of hemorrhage. Which
findings should the nurse anticipate?
1. Cold, clammy skin
2. Heart rate 120/min
2. Heart rate 120/min
3. Weak, thready pulse
4. Blood pressure 80/60
An older adult client reports recurring calf pain after walk-
ing 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
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
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 ettects associated with the therapy? SATA
1. WBC 1,200
1. WBC 1,200
5. Platelets 5,000
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
A nurse prepares a statt in-service on incident reports.
Which information should the nurse include? SATA
1. Risk management investigates the incident
1. Risk management investigates the incident
3. Reports include description of incident and actions tak-
2. A copy of report is placed in client's health record
en
3. Reports include description of incident and actions
taken
, ATI NCLEX Questions and Answers Graded A+
4. Reports are confidential and not shared with nonin-
volved statt 4. Reports are confidential and not shared with nonin-
5. Completion of report should be documented in the volved statt
nurses' notes
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 3. Consult the unit procedure manual for guidance
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.
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 1. Verify the admission medications prescribed by the
provider provider
2. Review the current medication regimen with the client 2. Review the current medication regimen with the client
3. Obtain the most recent list of mediations from the 3. Obtain the most recent list of medications from the
long-term care facility long-term care facility
4. Locate a list of discharge medications from the most 5. discuss any discrepancies with the health care provider
recent hospitalization.
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
2. Assist the client to ambulate to the bedside chair twice a day
a day 4. Complete vital signs that include oxygen saturation
3. Demonstrate to client the proper use of a bronchodila- every 4 hours
tor inhaler
4. Complete vital signs that include oxygen saturation
every 4 hours
, ATI NCLEX Questions and Answers Graded A+
5. Obtain a urine specimen from the client's indwelling
bladder catheter
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
3. Bronchitis receiving bronchodilator treatments
2. Facial lacerations and a subdural hematoma
5. Advanced regular diet two days post chole
3. Bronchitis receiving bronchodilator treatments
4. Exacerbation of myasthenia gravis admitted three hours
ago
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 3. Assess vital signs and LOC
2. Obtain HR and BP
3. Assess vital signs and LOC
4. Determine intensity of pain with ROM
Four days after a ventral hernia repair, a client who is
obese and has a history of COPD vomits and reports se-
vere abdominal pain. The oxygen saturation is 90%. Which
action should the nurse implement first?
3. Assess the surgical incision site
1. Administer ondansetron hcl IV
2. Encourage pursed lip breathing
3. Assess the surgical incision site
4. Apply low dose oxygen via nasal cannula
A nurse arrives at a work site explosion. Which client
should be triaged first? A client who has
2. Burns to the face and respiratory stridor
1. Fixed pupils an agonal respirations
2. Burns to the face and respiratory stridor
, ATI NCLEX Questions and Answers Graded A+
3. Type 2 DM who is disoriented
4. A closed fracture reporting "a pain level of 3"
A home health nurse is performing an admission assess-
ment 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"
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"
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?
4. Immerse the end of the chest tube in a bottle of sterile
1. Increase suction to the chest drainage system.
water
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
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
3. Start a new IV at another site and resume the transfusion
infiltration
at the new site
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 transfu-
sion at the new site
