ATI practice NCLEX questions and
Solutions.
An older adult client reports recurring calf pain after walking one block that disappears with rest. the client has
weak pedal pulses and the skin on the left lower extremity is shiny and cool to touch. Which nursing
intervention is appropriate at this time?
1. position left leg dependently
2. elevate left leg above the heart
3. immobilize left leg to prevent further injury
4. assess dorsiflexion and extension of left foot ANSWER - 1. position left leg dependently
a client receives a transfusion of packed RBC's and tells the nurse "my IV site is painful and looks swollen".
Which action should the nurse take?
1. continue to monitor site for signs of infection or infiltration.
2. double check blood type of unit of blood with another RN.
3. start a new IV at another site and resume transfusion.
4. discontinue the transfusion and send the remaining blood and tubing to lab. ANSWER - 3. start a new IV at
another site and resume transfusion.
a client who has recently undergone surgery for a new trach is now at home. the RN recognizes a need for
immediate intervention when the caregiver does which of the following?
1. suctions intermittently for 15 sec
2. places air humidifier at bedside
3. cuts 4x4 gauze to put around trach
4. removes ties before cleaning the trach ANSWER - 4. removes ties before cleaning the trach
, A nurse enters the room of a client who is lying on the floor. What should be the initial action of the RN?
1. examine pt for injuries
2. obtain pulse and blood pressure
3. assess VS and LOC
4. determine intensity of pain with ROM ANSWER - 3. assess VS and LOC
Four days after a ventral hernia repair, a client is obese and has a hx of COPD, vomits and reports severe
abdominal pain. O2 is 90%. Which action should the RN implement first?
1. administer ondansetron hcl IV
2. encourage pursed lip breathing
3. assess surgical incision
4. apply low dose O2 NC ANSWER - 3. assess surgical incision
A nurse arrives at a work site explosion. Which client should be triaged first?
1. fixed pupils and agonal respirations
2. burns to the face and respiratory stridor
3. type 2 diabetic who is disoriented
4. a closed fracture reporting 3/10 pain ANSWER - 2. burns to the face and respiratory stridor
Of the following what is an early sign of hemorrhage?
1. cold clammy skin
2. HR 120
3. weak, thready pulses
4. BP 80/66 ANSWER - 2. HR 120
A pt has a C3 spinal injury, which of the following VS take priority?
Solutions.
An older adult client reports recurring calf pain after walking one block that disappears with rest. the client has
weak pedal pulses and the skin on the left lower extremity is shiny and cool to touch. Which nursing
intervention is appropriate at this time?
1. position left leg dependently
2. elevate left leg above the heart
3. immobilize left leg to prevent further injury
4. assess dorsiflexion and extension of left foot ANSWER - 1. position left leg dependently
a client receives a transfusion of packed RBC's and tells the nurse "my IV site is painful and looks swollen".
Which action should the nurse take?
1. continue to monitor site for signs of infection or infiltration.
2. double check blood type of unit of blood with another RN.
3. start a new IV at another site and resume transfusion.
4. discontinue the transfusion and send the remaining blood and tubing to lab. ANSWER - 3. start a new IV at
another site and resume transfusion.
a client who has recently undergone surgery for a new trach is now at home. the RN recognizes a need for
immediate intervention when the caregiver does which of the following?
1. suctions intermittently for 15 sec
2. places air humidifier at bedside
3. cuts 4x4 gauze to put around trach
4. removes ties before cleaning the trach ANSWER - 4. removes ties before cleaning the trach
, A nurse enters the room of a client who is lying on the floor. What should be the initial action of the RN?
1. examine pt for injuries
2. obtain pulse and blood pressure
3. assess VS and LOC
4. determine intensity of pain with ROM ANSWER - 3. assess VS and LOC
Four days after a ventral hernia repair, a client is obese and has a hx of COPD, vomits and reports severe
abdominal pain. O2 is 90%. Which action should the RN implement first?
1. administer ondansetron hcl IV
2. encourage pursed lip breathing
3. assess surgical incision
4. apply low dose O2 NC ANSWER - 3. assess surgical incision
A nurse arrives at a work site explosion. Which client should be triaged first?
1. fixed pupils and agonal respirations
2. burns to the face and respiratory stridor
3. type 2 diabetic who is disoriented
4. a closed fracture reporting 3/10 pain ANSWER - 2. burns to the face and respiratory stridor
Of the following what is an early sign of hemorrhage?
1. cold clammy skin
2. HR 120
3. weak, thready pulses
4. BP 80/66 ANSWER - 2. HR 120
A pt has a C3 spinal injury, which of the following VS take priority?
