Prepare for the NCLEX-RN nursing board exam with these ATI practice questions and answers. This guide covers safe and effective care environment, health promotion, psychosocial integrity, and physiological integrity.
Q: During a home health assessment the nurse witnesses a school age child fall from a second story window. Which is the priority action?
Answer: Tell the child not to moveDo not rule out spinal cord injury
Q: A unit manager observes several nurses working throughout the day.. Which action represents a breach in client confidentiality ?
Answer: Posting positive information about a client on social media website.
Q: A client who is newly admitted requests information about advanced directives. The nurse should include which of the following statements in discussion ?
Answer: I will give you a pamphlet with written information about advanced directives.
Q: A nurse completes a home health assessment on an older adult who has a broken arm and burns to the chest. Which action is needed at this time?
Answer: Contact adult protective services.
Q: A client arrives to the ED and reports HA, neck stiffness and sensitivity to light. Which is the priority nursing action?
Answer: Implement droplet precautions- possible meningitis (highly contagious if bacterial)
Q: A bladder irrigation is prescribed for a client who has an occluded indwelling cath. Which action should nurse take when unsure of how to perform this procedure?
Answer: Refer to the policy and procedure manual
Q: A charge nurse reviews abbreviations in client documentation. Which is an approved entry?
Answer: Furosemide 60 mg PO daily
Q: A nurse participates in quality improvement to decrease hospital readmissions for clients who have heart failure. .Which action should the nurse expect to perform?
Answer: Compare performance to current practice standards
Q: A nurse assigns care for client who has DM to an LPN and a UAP. Which task should be given to the LPN?
Answer: Obtain capillary glucose
Q: A client with a stage IV pancreatic cancer decides to DC all treatment. Which action should the nurse take?
Answer: Ask client to discuss decision
Q: A nurse receives a client’s medication over the telephone from the provider. Which action should the nurse take?
Answer: Repeat the prescription back to the provider
Q: A nurse receives end of shift report. Which of the following client assessment findings should nurse address first ?
Answer: New onset of confusion in client with L femur fracture ( Fat emboli risk/ Hypoxia)
Q: A nurse should notify public health about which infections?
Answer: -gonorrhea-hep C-Chlamydia-Meningococcal
Q: A client with a new diagnosis of stage IV lung cancer, when partner requests the dx be withheld from the client, which action should the nurse take ?
Answer: Request additional information from partner
Q: A nurse reviews the plan of care for client who has myasthenia gravis. Which intervention requires a revision?
Answer: Assist with daily activities prior to medication admin
Q: A client who has COPD is prescribed ipatropium. The nurse should instruct the client to report which sx immediately ?
Answer: Eye pain
Q: An older adult client who is receiving a blood transfusion develops an increased BP and crackles bilaterally. Which medication should nurse administer?
Answer: Furosemide ( fluid overload)
Q: A nurse provides teaching to a client who is prescribed spironolactone. Nurse should limit the intake of which foods?
Answer: BananasTomatoesAvocadosSweet potatoes
Q: A client is prescribed acetaminophen 650 mg PO every 4 hours PRN. which finding should alert the nurse to question this prescription ?
Answer: reports drinking 6 beers daily
Q: A school age child with ADHD is observed having increased concentration and ability to complete tasks. Nurse recognizes which medication may contribute to this?
Answer: Methylphenidate
Q: An unresponsive client is brought in with a RR of 8 with pinpoint pupils. Which med should be given?
Answer: Naloxone
Q: A nurse providing discharge instructions to a client who is newly prescribed lisinopril. Which statement indicates teaching was effective?
Answer: -it is an emergency if mouth begins to swell-if I develop a cough my doctor will be notified-my K level will need to be monitored-getting up quickly may cause me to feel dizzy
Q: A nurse provides care to client receiving chemo. Which action is appropriate if it spills on the floor?
Answer: Use a spill kit
Q: A client has a sulfamethoxazole allergy, the nurse should question which medication ?
Answer: Glipizide
Q: A nurse prepares to administer morphine 2mg IV. The vial available has 4mg per 2 ml. Which action should be taken?
Answer: Waste 1 mL with another nurse
Q: The electronic medication list is different from the client’s medication. Which action should the home health nurse perform?
Answer: Clarify the prescription with the provider
Q: An older adult receiving TPN states, I am having trouble breathing. ” The nurse should perform which action?
Answer: Evaluate fluid volume status
Q: A client who has cellulitis reports a pain level of 2. The nurse should plan to administer which medication ?
Answer: Ibuprofen PO
Q: A client is prescribed sulcrafate for treatment of a duodenal ulcer. Which statements indicate effective teaching ?
Answer: -I should drink 2000 mL of water each day-This will turn into a paste and cover the ulcer-My diet will include more fruits + vegetables-This medication will be taken 1 hr before meals
Q: A client with a DVT is receiving heparin, current labs show a aPTT of 40 seconds. Which action should the nurse implement ?
Answer: Increase the infusion
Q: A young adult is prescribed levetiracetam for seizure disorder. Which information should the nurse discuss ?
Answer: Mild periods of drowsiness may occur during the day
Q: A client is prescribed clozapine. The nurse should monitor for which complication ?
Answer: Dyslipidemia
Q: A client is prescribed aldendronate tablets. Which information should be included in the teaching ?
Answer: Sit upright for 30 min after taking
Q: A client prescribed phenelzine asks Why must I stop adding parmesan cheese to pasta. The nurse understands which complication may occur with this ?
Answer: HTN Crisis
Q: A nurse should take which action before administering levothyroxine to a client on continuous enteral tube feeding.
Answer: Pause infusion pump for 30 minutes
Q: A nurse is caring for a client with an implanted venous port, which action should be implanted prior to administering medication?
Answer: Access port using a non coring needle
Q: Prior to administering scheduled enoxaparin, which lab should the nurse evaluate ?
Answer: Plts
Q: Client with acute pulmonary edema is receiving furosemide IV. Which is an appropriate action by the nurse ?
Answer: Administer over 2 minutes
Q: Which of the following identifiers should be used to ensure client safety ?
Answer: -name-birth date-phone number-facility arm band-photo ID
Q: A nurse is providing care to a client who has sealed radiation implant. Which actions should be implemented ?
Answer: -wear a lead apron when providing care-instruct visitors to stand 6 ft away-place caution radioactive material sign on door
Q: A school nurse is teaching a course on health and safety to 11 year old students. Which topics are appropriate for the class ?
Answer: -activity and exercise-STI and pregnancy-alcohol and drug use-peer pressure and violence-eating disorders and nutrition
Q: Which occurrences require an incident report ?
Answer: -eye glasses lost-visitor falls in the hallway
Q: Which information is needed to teach client on proper use of hearing aid?
Answer: -avoid hairspray while wearing aid-batteries should be removed when not in use-follow up with an audiologist
Q: A nurse provides end of life care to a client of Chinese heritage. Which ritual may be practiced by family after death ?
Answer: Oldest child bathes the body
Q: A client states they have not been sleeping well. Which activity may be recommended before bed ?
Answer: Take a warm bath
Q: A nurse provides discharge education to a client with MRSA. Which information should be included ?
Answer: -do not share athletic equipment with others-discard soiled bandages in sealed plastic bag-keep infected area covered with dry bandage-shower over baths-wash all uninfected skin prior to infected
Q: Which infectious diseases require droplet precautions ?
Answer: MumpsPertussisPneumonia
Q: A nurse provides teaching to client about the use of a cane. Which instructions should the nurse include ?
Answer: Hold the cane on the stronger side of the body
Q: A nurse teaches an older adult client about measures to prevent constipation. Which information should be included ?
Answer: Take docutase sodium as prescribed
Q: A nurse observes a stage I pressure ulcer on a client’s heel. Which treatment should the nurse initiate ?
Answer: Pressure relieving device
Q: A nurse provides teaching to a client with a newly applied fiberglass cast. Which instructions should the nurse discuss ?
Answer: -report numbness or tingling to provider-keep arm elevated above heart during rest-blow cool air with hair dryer to relieve itching-wrap with plastic prior to showering
Q: A nurse provides care for client who has dementia and is recovering from knee arthroplasty. Which finding requires intervention ?
Answer: facial grimacing
Q: A client requires VS every 30 minutes. Which action should the nurse implement when using an EBP device ?
Answer: compare initial reading with auscultation results
Q: A nurse is providing care to client on a clear liquid diet. Which food choices are included ?
Answer: -hard candy-chicken broth-fruit flavored gelatin
Q: A client requires an enteral feed. Which action should the nurse perform immediately following insertion ?
Answer: aspirate gastric contents to measure the pH
Q: A nurse provides care to a client who is agitated. Which would be appropriate to implement ?
Answer: -reduce room noise-play soothing music-assess for urinary retention-administer a benzo
Q: A nurse observes a staff member’s behavior when a client becomes angry. Which reaction requires immediate intervention ?
Answer: Walks away from the client
Q: After obtaining blood from a PICC, which action should the nurse take next ?
Answer: Flush with 20mL of NSS
Q: A client is admitted to a telemetry unity with sustained PVC tachycardia. Which medication should the nurse prepare to give ?
Answer: Adenosine
Q: A nurse provides care to client who was admitted reporting chest pain. Which diagnostic test should the nurse prioritize ?
Answer: Electrocardiogram
Q: A nurse provides care to a client with SIADH. Which lab values would be expected ?
Answer: *Sodium 128 (hyponatremia)*Urine specific gravity ( 1.035) high(Decreased urine output)
Q: A nurse provides care for client who has a JP drain. Which action will ensure proper function ?
Answer: keep bulb compressed
Q: A nurse provides education to a preoperative client regarding the use of an IS. Identify the sequence to follow:
Answer: 1. Sit up2. Create tight seal around mouthpiece3. Inhale slowly4. Hold breathe for 3-5 seconds5. Exhale slowly6. Perform 10 per hour while awake
Q: A nurse plans care for a client who needs continuous ambulatory peritoneal dialysis. Which actions are appropriate ?
Answer: -notify provider of cloudy or opaque effluent-apply mask to client during system connect and disconnect-warm bag by applying heating pad prior to installation
Q: A nurse plans care for a client who has a serum K of 7. Which actions should be implemented ?
Answer: -place on a cardiac monitor-serum Crt level-infuse 100 ml of 10% glucose IV-begin IV infusion of regular insulin-sodium polys
Q: A nurse provides care to client who is on continuous ECG monitoring and observes rhythm (40 BPM Brady), which activities should be implemented ?
Answer: obtain a BP
Q: A client is receiving oxygen at 60% via a simple face mask. ABG shows : pH 7.31, PaO299, CO2 51, CO3 28. Which action should the nurse implement ?
Answer: decrease oxygen
Q: A nurse reviews ABG and the findings include : pH 7.48, PaCO2 44, Co3 3.. this shows which imbalance?
Answer: Uncompensated metabolic alkalosis(ROME: HIGH pH HIGH bicarb) 0/