ATI RN VATI COMPREHENSIVE PREDICTOR FORM A ||
2025 NCLEX READY FOR A GUARANTEED PASS
TESTBANK
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the
following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Prepare the client for a cesarean section
A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of
the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Ototoxicity
,A nurse is assessing an infant who has water intoxication. Which of the following findings should the
nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Generalized edema
A home health nurse is conducting an initial home visit for a client who has terminal breast cancer.
The client has two school-age children and a limited support system. Which of the following is the
priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Inform the client of available community resources
A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Clear fluid drainage from the nares
A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical
findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Profuse milky white discharge
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which
of the following statements indicates the newly licensed nurse understands the purpose of the
technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
,C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
This technique decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of the following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Dry the newborn
A nurse is planning to provide community education about viral hepatitis. Which of the following
should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood
Clients who have a history of viral hepatitis are unable to donate blood
A nurse in a residential mental health facility is planning care for a new client who has obsessive
compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts
Gradually decrease the time allowed for ritualistic behavior
A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's
BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity
Healthy weight
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal
assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last
contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of
the following is a priority action by the nurse?
, A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid
Check the FHR
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
Monitor the client for 1 hr after meals
A nurse is performing a skin assessment on a client who has risk factors for development of skin
cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery
Asymmetric, with variegated coloring
A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the
following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead
Dim the lights in the room prior to the examination
A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following
actions should the nurse identify as an indication that the newly licensed nurse understands wound
irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom
Irrigates the wound from the top to the bottom
A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of
consciousness. Which of the following interventions should the nurse include in the plan of care?
2025 NCLEX READY FOR A GUARANTEED PASS
TESTBANK
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite
at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the
following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Prepare the client for a cesarean section
A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of
the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Client found lying on the floor near the bedside table
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Ototoxicity
,A nurse is assessing an infant who has water intoxication. Which of the following findings should the
nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Generalized edema
A home health nurse is conducting an initial home visit for a client who has terminal breast cancer.
The client has two school-age children and a limited support system. Which of the following is the
priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Inform the client of available community resources
A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Clear fluid drainage from the nares
A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of
gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical
findings are associated with this infection?
A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Profuse milky white discharge
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which
of the following statements indicates the newly licensed nurse understands the purpose of the
technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
,C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
This technique decreases the risk of subcutaneous infiltration
10. A nurse is caring for a full-term newborn immediately following birth. Which of the following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn's eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Dry the newborn
A nurse is planning to provide community education about viral hepatitis. Which of the following
should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
D. Clients who have a history of viral hepatitis are unable to donate blood
Clients who have a history of viral hepatitis are unable to donate blood
A nurse in a residential mental health facility is planning care for a new client who has obsessive
compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts
Gradually decrease the time allowed for ritualistic behavior
A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's
BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity
Healthy weight
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal
assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last
contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of
the following is a priority action by the nurse?
, A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid
Check the FHR
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
Monitor the client for 1 hr after meals
A nurse is performing a skin assessment on a client who has risk factors for development of skin
cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery
Asymmetric, with variegated coloring
A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the
following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead
Dim the lights in the room prior to the examination
A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following
actions should the nurse identify as an indication that the newly licensed nurse understands wound
irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom
Irrigates the wound from the top to the bottom
A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of
consciousness. Which of the following interventions should the nurse include in the plan of care?
