@PROFDOCDIGITALLIBRARIES
NSG 4060 Comprehensive ATI Practice B
A nurse is assessing a client who received 2 units of packed RBCs 48hrs 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?
PR
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.
O
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
FD
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
O
should administer?
18 g
C
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.
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.
,@PROFDOCDIGITALLIBRARIES
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
PR
should plan to perform which of the following actions?
Instruct the client to avoid coughing during the procedure.
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.
O
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.
FD
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?
O
Fiber
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
inflammation.
C
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 the following sites
should the nurse select when initiating the IV for the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous t issue.
, @PROFDOCDIGITALLIBRARIES
A nurse is developing a client education program a bout osteoporosis for older adult clients. The
nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle.
This is a risk factor for osteoporosis. The nurse should encourage older adult clients to
engage in weight-bearing exercises because t hey will promote bone health by
increasing calcium and phosphorus levels.
A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and
extremities. Which of t he following interventions should the nurse identify as the priority?
Initiate transmission-based precautions
When using the urgent vs nonurgent approach to client care, the nurse should determine
that the priority action is to initiate transmission-based precautions for the child. The
child most likely has varicella. Therefore, the nurse should isolate the child to prevent the
PR
spread of the infection.
A nurse is caring for a c lient who has a clogged percutaneous gastrostomy feeding tube. Which
of the following actions should the nurse take first?
Change the position of the client.
O
When providing client care, the nurse should use the least restrictive intervention first.
Therefore, the nurse should reposition the client to remove any kinks in the tube, which
can lead to clogging. If this method is unsuccessful, t he nurse should attempt to flush or
FD
aspirate the client’s tube to remove the clog.
A home health care nurse is developing a teaching plan for a client who has a new ileostomy.
Which of the following i nstructions should the nurse include?
Empty the appliance when it is one-third t o one-half full.
O
The ileostomy pouch should be emptied when it is o ne-third to one-half full to prevent
stool leakage and skin irritation.
C
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 caring for four clients. Which of the following tasks should the nurse delegate to a
CNA?
Arrange the lunch tray for a client who has a hip fracture.
Assisting a client with meals is within the range of function of the CNA.
NSG 4060 Comprehensive ATI Practice B
A nurse is assessing a client who received 2 units of packed RBCs 48hrs 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?
PR
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.
O
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
FD
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
O
should administer?
18 g
C
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.
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.
,@PROFDOCDIGITALLIBRARIES
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
PR
should plan to perform which of the following actions?
Instruct the client to avoid coughing during the procedure.
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.
O
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.
FD
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?
O
Fiber
The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and
inflammation.
C
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 the following sites
should the nurse select when initiating the IV for the client?
Radial vein of the inner arm.
This site will have adequate subcutaneous t issue.
, @PROFDOCDIGITALLIBRARIES
A nurse is developing a client education program a bout osteoporosis for older adult clients. The
nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle.
This is a risk factor for osteoporosis. The nurse should encourage older adult clients to
engage in weight-bearing exercises because t hey will promote bone health by
increasing calcium and phosphorus levels.
A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and
extremities. Which of t he following interventions should the nurse identify as the priority?
Initiate transmission-based precautions
When using the urgent vs nonurgent approach to client care, the nurse should determine
that the priority action is to initiate transmission-based precautions for the child. The
child most likely has varicella. Therefore, the nurse should isolate the child to prevent the
PR
spread of the infection.
A nurse is caring for a c lient who has a clogged percutaneous gastrostomy feeding tube. Which
of the following actions should the nurse take first?
Change the position of the client.
O
When providing client care, the nurse should use the least restrictive intervention first.
Therefore, the nurse should reposition the client to remove any kinks in the tube, which
can lead to clogging. If this method is unsuccessful, t he nurse should attempt to flush or
FD
aspirate the client’s tube to remove the clog.
A home health care nurse is developing a teaching plan for a client who has a new ileostomy.
Which of the following i nstructions should the nurse include?
Empty the appliance when it is one-third t o one-half full.
O
The ileostomy pouch should be emptied when it is o ne-third to one-half full to prevent
stool leakage and skin irritation.
C
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 caring for four clients. Which of the following tasks should the nurse delegate to a
CNA?
Arrange the lunch tray for a client who has a hip fracture.
Assisting a client with meals is within the range of function of the CNA.
