Updated 2026 | 190+ Questions and Answers | Virtual ATI Green Light
Comprehensive Predictor Exam Prep, Comprehensive Study Guide, Practice Exam,
Test Bank, ATI RN Review, NCLEX-RN Readiness, Medical-Surgical Nursing,
Pharmacology, Fundamentals of Nursing, Maternal-Newborn, Pediatrics, Mental
Health, Leadership & Management, Clinical Judgment, Prioritization, Delegation,
Detailed Rationales and Complete Revision Material
Question 1: A nurse is caring for a client who is postoperative and has a new
prescription for enoxaparin. Which of the following actions should the nurse
take?
A. Administer the medication via the intramuscular route.
B. Expel the air bubble from the prefilled syringe before injection.
C. Inject the medication into the client's vastus lateralis muscle.
D. Pinch the skin fold during the injection and do not rub the site after.
CORRECT ANSWER: D. Pinch the skin fold during the injection and do not rub
the site after.
Rationale: Enoxaparin is a low-molecular-weight heparin administered subcutaneously.
The nurse should pinch the skin fold to administer the injection into the subcutaneous
tissue and avoid rubbing the site to prevent bruising. It is not given IM, the air bubble
should not be expelled (it prevents medication loss), and the abdomen is preferred, not
the vastus lateralis.
Question 2: A client with a new diagnosis of type 1 diabetes mellitus is being
discharged. Which of the following statements by the client indicates a need
for further teaching regarding foot care?
A. "I will inspect my feet daily for any blisters or cuts."
B. "I will file my toenails straight across."
C. "I will soak my feet in warm water every evening."
D. "I will wear white cotton socks to detect drainage."
CORRECT ANSWER: C. "I will soak my feet in warm water every evening."
Rationale: Soaking the feet can lead to maceration of the skin and increase the risk of
infection due to impaired sensation and healing in diabetic clients. Daily inspection,
filing nails straight across, and wearing white socks are appropriate foot care practices.
Question 3: A nurse is assessing a client with heart failure who is receiving
digoxin. Which of the following findings is a sign of digoxin toxicity?
A. Heart rate of 62 beats per minute
B. Blood pressure of 118/72 mm Hg
C. Anorexia and visual disturbances
D. Urine output of 60 mL/hour
,CORRECT ANSWER: C. Anorexia and visual disturbances
Rationale: Signs of digoxin toxicity include gastrointestinal symptoms such as anorexia,
nausea, and vomiting, as well as visual disturbances like yellow-green halos. A heart rate
of 62, BP of 118/72, and urine output of 60 mL/hour are within normal limits and not
indicative of toxicity.
Question 4: A nurse in the emergency department is caring for a client who
was bitten by a dog. Which of the following actions is the priority?
A. Administer a tetanus vaccine.
B. Irrigate the wound with copious amounts of normal saline.
C. Apply a sterile dressing.
D. Obtain a wound culture.
CORRECT ANSWER: B. Irrigate the wound with copious amounts of normal
saline.
Rationale: The priority action is to clean the wound through irrigation to remove debris
and bacteria, reducing the risk of infection. The ABCs and wound cleaning take
precedence over tetanus administration, dressing, and culture, which are secondary
interventions.
Question 5: A nurse is preparing to administer a blood transfusion to a client.
Which of the following actions is most important to prevent a transfusion
reaction?
A. Verify the client's blood type and crossmatch results with another nurse.
B. Start the transfusion at a slow rate for the first 15 minutes.
C. Check the expiration date of the blood product.
D. Monitor the client's vital signs every 15 minutes.
CORRECT ANSWER: A. Verify the client's blood type and crossmatch results
with another nurse.
Rationale: The most critical step to prevent a hemolytic transfusion reaction is ensuring
the correct blood product is given to the correct client. Two nurses must verify the
blood type, crossmatch, client identity, and unit number. The other actions are important
but secondary to correct identification.
Question 6: A client is receiving chemotherapy and has a platelet count of
20,000/mm³. Which of the following precautions should the nurse implement?
A. Place the client in a private room with negative pressure.
B. Avoid administering any intramuscular injections.
,C. Restrict fresh fruits and vegetables in the diet.
D. Wear a mask when entering the client's room.
CORRECT ANSWER: B. Avoid administering any intramuscular injections.
Rationale: With a platelet count of 20,000/mm³, the client is at high risk for bleeding.
The nurse should avoid IM injections due to bleeding risk, apply pressure to
venipuncture sites, and use soft toothbrushes. Negative pressure, neutropenic diet, and
masks are for neutropenia, not thrombocytopenia.
Question 7: A nurse is assessing a client with chronic obstructive pulmonary
disease (COPD). Which of the following findings is expected?
A. Diminished breath sounds with prolonged expiration.
B. Increased anterior-posterior (AP) chest diameter.
C. Use of accessory muscles during inspiration.
D. All of the above.
CORRECT ANSWER: D. All of the above.
Rationale: COPD is characterized by hyperinflation, which leads to a barrel chest
(increased AP diameter), use of accessory muscles, and diminished breath sounds with
prolonged expiration due to air trapping. All options are expected findings in a client
with COPD.
Question 8: A nurse is providing discharge teaching to a client who has a new
prescription for warfarin. Which of the following over-the-counter medications
should the client avoid?
A. Acetaminophen.
B. Ibuprofen.
C. Diphenhydramine.
D. Loratadine.
CORRECT ANSWER: B. Ibuprofen.
Rationale: Ibuprofen is an NSAID that can increase the risk of gastrointestinal bleeding
when taken with warfarin, an anticoagulant. Acetaminophen is safer in limited doses for
pain, while diphenhydramine and loratadine do not have significant interactions.
Question 9: A nurse is caring for a client with a tracheostomy. Which of the
following actions should the nurse take to maintain a patent airway?
A. Instill normal saline into the tracheostomy tube to loosen secretions.
B. Suction the tracheostomy tube for 15 seconds or less.
, C. Change the tracheostomy ties once per shift.
D. Deflate the cuff before suctioning.
CORRECT ANSWER: B. Suction the tracheostomy tube for 15 seconds or less.
Rationale: Suctioning should not exceed 15 seconds to prevent hypoxia and tissue
damage. Instilling saline is controversial and not routinely recommended; changing ties
is not done every shift, and deflating the cuff before suctioning can allow aspiration of
secretions.
Question 10: A client is experiencing chest pain. The nurse administers
sublingual nitroglycerin. Which of the following statements indicates the
medication is effective?
A. "My headache is getting worse."
B. "I feel a tingling sensation under my tongue."
C. "My chest pain has decreased."
D. "My pulse is now 110 beats per minute."
CORRECT ANSWER: C. "My chest pain has decreased."
Rationale: The therapeutic effect of nitroglycerin is relief of chest pain due to coronary
vasodilation. Headache is a side effect, tingling suggests potency (but not efficacy), and
tachycardia may be a compensatory response to hypotension, not a sign of
effectiveness.
Question 11: A nurse is assessing a newborn who is 2 hours old. Which of the
following findings should be reported to the provider?
A. Heart rate of 140/min.
B. Axillary temperature of 36.5°C (97.7°F).
C. Respiratory rate of 68/min.
D. Blood glucose of 55 mg/dL.
CORRECT ANSWER: C. Respiratory rate of 68/min.
Rationale: A normal respiratory rate for a newborn is 30-60 breaths/min. A rate of 68 is
tachypneic and could indicate respiratory distress, hypoglycemia, or infection, and
should be reported. A heart rate of 140 is normal, temperature of 36.5°C is within
normal limits (though on the lower side), and 55 mg/dL is acceptable for a newborn.
Question 12: A client is prescribed furosemide for heart failure. Which of the
following adverse effects should the nurse monitor for?
A. Hyperkalemia.
B. Hypokalemia.