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NSG 4060 Comprehensive ATI Practice B 2021/2022
A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago.
Which of the following findings should indicate to the nurse that the therapy
has been effective?
Hemoglobin 14.9 g/dL
The nurse should identify that packed RBCs a re administered to
clients who have a decreased level of hemoglobin or hematocrit. This
h emoglobin level is within the expected reference range of 14 to 18
g/dL for males and 12 to 16 g/dL for females, indicating the therapy
has been effective.
A nurse working in a n emergency department is triaging four clients. Which
of the following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs.
Using the stable vs unstable approach t o client care, the nurse should
recommend priority treatment for the client who has u nstable vital
signs because this client requires immediate treatment to reduce the
risk of further injury o r possible death.
A nurse is caring for a c lient who has hyperthyroidism. Which of the
following findings should the nurse expect?
Tremors
Tremors are a manifestation of hyperthyroidism, along with tachycardia,
diaphoresis, weight loss, insomnia, and exophthalmia.
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A nurse is caring for a c lient who has fluid volume overload. Which of the
following tasks should the nurse delegate t o the CNA?
Measure the client’s daily weight
It is within the CNAs range of function to measure a client’s daily
weight, so the nurse should delegate this task to them.
A nurse is preparing t o administer mannitol 0.2g/kg IV bolus over 5 min as a
test dose to a client who has severe oliguria. The client weighs 198lb. What
is t he amount in grams the nurse should administer?
18 g
A nurse is conduction a physical examination for an adolescent and is
assessing the range of motion of the legs. W hich of the following images
indicates the adolescent is abducting the hip joint?
In the correct image, the adolescent is abduction the hip joint by
moving the leg away from the midline of the body.
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A nurse is reviewing the laboratory report of a client who has end-stage
kidney disease and received hemodialysis 24 yr ago. Which of the
following lab values should the nurse report to the provider?
Sodium 148 mEq/L
The nurse should report this sodium level because it is a bove the
expected reference range of 136 to 145 mEq/L, indicating
hypernatremia. Clients who have kidney disease often retain sodium
and require sodium-restricted diets.
A nurse is assessing a school-aged child who has bacterial meningitis. Which
of the following findings should the n urse expect?
Nuchal rigidity
This is a manifestation of bacterial meningitis.
A nurse is assessing a newborn’s heart rate. Which of the following actions
should the nurse take?
Auscultate the apical pulse at least 1 min.
The nurse should auscultate the apical pulse to obtain an accurate
assessment of heart rate and rhythm. Auscultation of a newborn’s
heart sounds can be difficult because of the rapid rate and the
transmission of respiratory sounds.
A nurse is preparing t o assist with a thoracentesis for a client who has
pleurisy. The nurse should plan to perform which of the following actions?
Instruct the client to avoid coughing during the procedure.
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It is important for the nurse to remind the client to avoid coughing and
to lie still during a thoracentesis to avoid puncturing the pleura.
A nurse in the ED is a ssessing a preschooler who has a facial laceration. The
nurse should identify which of the f ollowing findings as a potential indication
of child sexual abuse?
The child exhibits discomfort while walking.
The nurse should identify this finding as a potential indication of child
sexual abuse.
A nurse is preparing t o teach about dietary management to a client who
has Crohn’s disease and an enteroenteric f istula. Which of the following
nutrients should the nurse instruct the client to decrease in their d iet?
Fiber
The nurse should instruct the client to consume a low-fiber diet to
reduce diarrhea and inflammation.
A nurse is caring for a c lient who has a prescription for a continuous passive
motion (CPM) machine following a total knee arthroplasty. Which of the
following actions should the nurse take?
Turn off the CPM machine during
mealtime. This promotes client
comfort and dietary intake.
A nurse is preparing t o initiate IV access for an older adult client. Which of
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