WCU NH N480 / NURS 480 Section 1M – Exam 1 ATI Assessment | Complete Answered Questions & Answers | Updated 2026.

West Coast University NURS 480 (NH N480) Sect 1M Exam 1 – ATI Assessment | Complete Answered Review Guide | Latest 2026 ### 1. A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has re-expanded? A. No fluctuations in the water seal chamber B. Oxygen saturation of 95% C. No reports of pleuritic chest pain D. Occasional bubbling in the water-seal chamber ### 2. A nurse is caring for a client who has a new chest tube in place to closed-chest water-seal drainage and suction. The nurse should observe the client for which of the following indications of a problem in the drainage system? A. Continuous bubbling in the water-seal chamber B. Occasional bubbling in the water-seal chamber C. Constant bubbling in the suction-control chamber D. Fluctuations in the fluid level in the water-seal chamber ### 3. A nurse is caring for a client who has just had a bronchoscopy. Which of the following is an appropriate nursing action? A. Withhold food and liquids until the client’s gag reflex returns B. Irrigate the client’s throat every 4 hr C. Have the client refrain from talking for 24 hr D. Suction the client’s oropharynx frequently ### 4. A nurse is caring for a client who has just developed pulmonary embolism. The nurse should prepare to administer which of the following medications? A. Heparin B. Furosemide (Lasix) C. Dexamethasone (Decadron) D. Atropine ### 5. The nurse assesses a client with dyspnea, decreased breath sounds, tracheal deviation, and pulse oximetry reading of 86%. What is the nurse’s interpretation of these findings? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Acute respiratory distress syndrome ### 6. The nurse observes the nursing student suctioning the client. Which intervention on the student nurse’s part has the greatest potential to cause tissue damage? A. Applying suction when the catheter is inserted B. Oxygen saturation postsuctioning of 93% C. Hyperoxygenating the client after removing the suction catheter D. Applying intermittent suction ### 7. A client has the following arterial blood gas values: pH 7.52, PaO₂ 50 mm Hg, PaCO₂ 28 mm Hg, HCO₃ 24 mEq/L. Based upon the client’s PaO₂, which of the following conclusions would be accurate? A. The client is severely hypoxic. B. The oxygen level is low but poses no risk for the client. C. The client’s PaO₂ level is within normal range. D. The client requires oxygen therapy with very low oxygen concentrations. ### 8. A client who is intubated and receiving mechanical ventilation (PEEP) has a nursing diagnosis for Risk for Infection. The nurse should include which of the following in the care of this client? **(Select all that apply.)** ### 9. The nurse participating in a client care conference with other health team members is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is: A. Collapse of alveoli and decreased compliance. B. Atelectasis and viral infection. C. Bronchoconstriction and stridor. D. Decreased ciliary action and retained secretions. ### 10. A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action? A. Reposition the client. B. Increase the client’s wall suction. C. Strip the client’s chest tube. D. Clamp the client’s chest tube. ### 11. A nurse is monitoring a client who is under conscious sedation. Which of the following findings requires immediate intervention? A. No response to verbal stimuli B. Oxygen saturation level of 94% C. Blood pressure reading of 108/62 mm Hg D. Decreased muscle tone ### 12. A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires: A. Pre-oxygenation prior to suctioning. B. A cardiology consult. C. Less frequent suctioning. D. An antidysrhythmic medication. ### 13. Order: Gentamicin 1.5 mg/kg IV Q8H over 60 minutes. Supply: Gentamicin 100 mg per 100 mL. The patient weighs 185 lbs. How many mL per hour will the nurse infuse? Round to the nearest whole number. ### 14. A nurse is caring for a client experiencing moderate to severe pain. The client is scheduled to receive IV morphine as ordered. Which of the following assessment findings should be a concern for the nurse? A. Blood pressure: 88/52 mm Hg B. Client reports of passing stool once in 7 days C. Respiratory rate: 14 breaths per minute D. SpO₂: 98% on room air ### 15. A client is receiving a continuous IV heparin infusion for a pulmonary embolism. The client complains of abdominal pain and black tarry stool. Which of the following should the nurse anticipate as the next intervention? A. Administer protamine sulfate as ordered. B. Monitor APTT C. Monitor PTT D. Administer Vitamin K as ordered. ### 16. A nurse is working in the ICU and notices signs of alarm fatigue among the staff, including delayed responses to alarms and increased irritability. Which of the following interventions should the nurse prioritize to address alarm fatigue and improve patient safety? A. Review and adjust alarm settings to ensure they are individualized for each patient. B. Increase the volume of all alarms to ensure they are heard clearly. C. Encourage staff to ignore non-critical alarms to focus on more urgent needs. D. Limit the number of alarms by removing unnecessary monitoring equipment. ### 17. The nurse is assigned to four clients. Which of the following clients should the nurse assess first? A. A client with rib fractures and severe pain (8/10) who is having difficulty breathing B. A client admitted for seven days with a chest tube whose water seal chamber has no bubbling C. A client with COPD with a SaO₂ of 94% with the following ABG results: pH 7.35, PaCO₂ 45, HCO₃ 26 D. A client admitted to the unit for a random blood sugar of 350 mg/dL with a fruity breath ### 18. A nurse is assessing a client who was admitted after a motor vehicle accident and has multiple rib fractures. The nurse observes paradoxical chest movement, pain on inspiration, and shallow breathing. Which of the following is the most likely condition for this client? A. Flail chest B. Tension pneumothorax C. Pulmonary contusion D. Acute Respiratory Distress Syndrome ### 19. A nurse is caring for a client with acute respiratory failure who has been placed on mechanical ventilation. The client is exhibiting signs of hypoxemia, including confusion, tachypnea, and an oxygen saturation of 85%. Crackles are heard on auscultation. Which of the following interventions should the nurse prioritize? A. Suction the client’s airway. B. Change the ventilator settings. C. Administer Lorazepam as ordered. D. Administer propofol as ordered. ### 20. A nurse is caring for a client on mechanical ventilation. The ventilator alarm goes off with the message “Low Pressure Alarm.” Which of the following is the most likely cause of the alarm? A. Disconnection of the ventilator from the endotracheal tube B. A kink in the ventilator tubing C. An increase in the client’s tidal volume D. A high-pressure setting on the ventilator ### 21. A nurse is assessing a client on a ventilator and notices that the client's respiratory rate setting on the ventilator is high. Which of the following conditions is anticipated by the nurse once the ABG for this client has been received? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis ### 22. Which of the following ABG findings is consistent with a diagnosis of Acute Respiratory Failure? A. pH 7.23, PaCO₂ 58, HCO₃ 19, PaO₂ 58 B. pH 7.45, PaCO₂ 37, HCO₃ 24 C. pH 7.74, PaCO₂ 27, HCO₃ 25 D. pH 7.10, PaCO₂ 40, HCO₃ 17 ### 23. A nurse is caring for a mechanically ventilated client receiving a propofol infusion for sedation. To evaluate the clinical effectiveness of the propofol, which of the following findings would be the most appropriate indicator that the medication is working as intended? A. The client is responsive to verbal commands and easily aroused yet calm and comfortable. B. The client is completely unresponsive and does not react to any painful stimuli. C. The client exhibits frequent episodes of agitation and attempts to self-extubate. D. The client shows signs of shallow breathing and significantly reduced tidal volumes. ### 24. A 70-year-old client is receiving an intravenous infusion of vancomycin for MRSA pneumonia. Thirty minutes into the infusion, the nurse observes that the client has developed flushing, itching, and erythema over the face, neck, and upper torso. Which of the following actions should the nurse take first? A. Stop the infusion. Notify the provider. Restart at a slower rate. B. Administer an antipyretic and continue the infusion at the current rate. C. Increase the infusion rate. D. Dilute the vancomycin solution and continue the infusion. ### 25. The nurse is assigned to four clients. Which of the following clients should be assessed first? A. An elderly client with an ABG reading of pH 7.30, PaCO₂ 60 and PaO₂ 55 mmHg with bluish lips and fingers B. A client with rib fractures who is complaining of mild pain C. A client with a chest tube whose water-seal drainage system shows intermittent bubbling who is reading a book D. A client with a history of asthma who is on oxygen therapy with an SpO₂ of 96% ### 26. A nurse is caring for a client in the ICU when the client suddenly becomes unresponsive, stops breathing, and no pulse is palpable. Which of the following actions should the nurse perform immediately? A. Initiate a Code Blue. B. Activate the Rapid Response Team. C. Reassess vital signs and call for an ECG. D. Administer supplemental oxygen and monitor the client. ### 27. A nurse is working in the emergency department when a client arrives with severe chest pain and shortness of breath. The client does not have insurance and states they are unable to pay for care. Which of the following actions is the nurse required to take according to the Emergency Medical Treatment and Labor Act (EMTALA)? A. Provide a medical screening examination and stabilize the client. B. Contact the client’s insurance company to confirm coverage before providing care. C. Ask the client to sign a financial responsibility form before offering treatment. D. Direct the client to a nearby urgent care center to treat the symptoms. ### 28. A nurse is assessing a client who is suspected of being sexually assaulted. Which of the following signs and symptoms would the nurse identify as potential indicators of sexual assault? A. Vaginal bleeding, bruising, and genital swelling. B. Sudden onset of fever, joint pain, and a positive urine culture for bacteria. C. Complaints of headache, nausea, and dizziness after consuming alcohol. D. Redness and swelling at the injection site. ### 29. A nurse is caring for a client who is receiving heparin therapy. The healthcare provider has ordered an activated partial thromboplastin time (aPTT) test to monitor the client's response to the medication. The therapeutic range for the aPTT is 60–80 seconds. The most recent aPTT result is 95 seconds. Which of the following actions should the nurse take? A. Assess for petechiae, coffee-ground emesis, or abdominal pain. B. Continue the heparin infusion at the current rate. C. Administer a heparin bolus. D. Increase the heparin infusion rate. ### 30. A nurse is caring for a client in the ICU who has been intubated and is receiving mechanical ventilation. The healthcare provider has ordered enteral nutrition via a feeding tube. Which of the following interventions is most important to prevent complications associated with enteral nutrition in the ICU? A. Elevate the head of the bed to at least 30–45 degrees during and after feeding. B. Administer the feeding at a rapid rate to ensure adequate caloric intake. C. Provide enteral nutrition in the morning to ensure it is well tolerated throughout the day. D. Monitor for diarrhea and constipation only after the first 48 hours of feeding. ### 31. A nurse is caring for a 78-year-old client in the Intensive Care Unit (ICU) who is disoriented, weak, and at high risk for falls. Which intervention should the nurse implement first to reduce the injury from falls? A. Keep the client’s bed in the lowest position with side rails up and call light within reach. B. Apply physical restraints to prevent the client from getting out of bed. C. Administer a sedative to promote rest and decrease agitation. D. Request a sitter to stay with the client at all times. ### 32. A nurse is preparing to administer heparin 3,000 units by IV bolus. Available is heparin injection 5,000 units/mL. How many mL should the nurse administer? Round the answer to the nearest tenth. ### 33. A nurse is preparing to titrate morphine 6 mg via IV bolus to a client. The amount available is morphine 8 mg/mL. How many mL should the nurse administer per dose? Round the answer to the nearest hundredth. ### 34. A nurse is preparing to administer vancomycin 500 mL in 100 mL of dextrose 5% in water (D5W) to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? Round the answer to the nearest whole number. ### 35. A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? Round the answer to the nearest whole number. ### 36. A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. ### 37. A nurse in the intensive care unit (ICU) is verifying the placement of a newly inserted nasogastric tube (NGT) in a ventilated client receiving enteral nutrition. Which method provides the most accurate confirmation of proper NGT placement? A. Obtaining an abdominal X-ray B. Observing for signs of respiratory distress during insertion C. Auscultating over the epigastrium while injecting air into the tube D. Aspirating gastric contents and assessing pH ### 38. A nurse is participating in a mass casualty incident where the disaster triage system is being used. The nurse is assigned to assess and tag patients based on severity. Which of the following patients should be assigned a red tag? A. A 32-year-old patient with trauma to the chest with a wound on the chest that makes sucking noises every time they breathe. B. A 45-year-old patient with a large laceration on the leg and stable vital signs. C. A 30-year-old patient with minor abrasions and alert but experiencing mild anxiety. D. A 50-year-old patient with a fractured arm with a HR of 95 bpm, Temp of 97°F, SaO₂ 96%, and BP of 120/86 mmHg. ### 39. A nurse is caring for a patient who is on a mechanical ventilator and has an artificial airway in place. The nurse needs to perform closed chest suctioning to clear secretions from the patient's airway. Which of the following is the most important action for the nurse to take before and during the suctioning procedure? A. Pre-oxygenate the patient with 100% oxygen before suctioning. B. Increase the ventilator settings to ensure adequate ventilation during suctioning. C. Suction continuously for 30 seconds to remove as much secretions as possible. D. Place the patient in a supine position to maintain optimal airway clearance. ### 40. A nurse in the post-anesthesia care unit (PACU) is assessing a client who was recently extubated. The nurse notes that the client has inspiratory stridor and labored breathing. Which of the following complications should the nurse suspect? A. Laryngeal edema B. Right mainstem bronchus intubation C. Mucus plug obstruction D. Tension pneumothorax ### 41. Which client is at highest risk for post-extubation laryngeal edema? A. A 42-year-old client who was intubated for 36 hours after surgery B. A 60-year-old client with COPD who was intubated for 4 hours C. A 75-year-old client with Parkinson’s disease who was intubated for 24 hours D. A 55-year-old client with pneumonia who was intubated for 8 hours ### 42. A ventilated patient requires continuous sedation with Propofol (Diprivan) at 5 mcg/kg/min. The patient weighs 75 kg. The pharmacy provides Propofol 10 mg/mL in a 100 mL vial. At what rate (mL/hr) should the nurse set the IV pump to deliver the prescribed dose? Round to the nearest whole number. ### 43. A ventilated ICU patient with a pulmonary embolism (PE) requires continuous heparin infusion at 18 units/kg/hr. The patient weighs 90 kg. The pharmacy provides Heparin 25,000 units in 500 mL of normal saline. At what rate (mL/hr) should the nurse set the IV pump? Round to the nearest whole number. ### 44. A nurse is caring for a mechanically ventilated client with HIV/AIDS who was admitted for Pneumocystis jirovecii pneumonia (PJP). Which intervention is most important to reduce the risk of ventilator-associated pneumonia (VAP) in this client? A. Perform oral care with chlorhexidine every 2–4 hours. B. Administer bronchodilators to prevent airway inflammation. C. Place the client in the Trendelenburg position to improve lung drainage. D. Delay suctioning to minimize airway irritation. ### 45. A nurse working in the emergency department (ED) is caring for a client with severe abdominal pain and vomiting. The client requests transfer to a nearby private hospital before receiving a medical screening exam. Which action by the nurse aligns with EMTALA regulations? A. Perform a medical screening exam (MSE) to determine if an emergency condition exists before transfer. B. Honor the client’s request and arrange for immediate transfer. C. Require the client to sign a waiver stating they refused treatment before allowing them to leave. D. Delay treatment until the hospital verifies the client’s insurance status. ### 46. A nurse is caring for a client with pleural effusion who reports worsening dyspnea and pleuritic chest pain. Which intervention is the most appropriate to help relieve the client’s symptoms? A. Position the client in a high-Fowler’s position to improve lung expansion. B. Place the client in a supine position to maximize lung expansion. C. Encourage deep breathing and coughing to clear secretions. D. Restrict fluid intake to decrease pleural fluid accumulation. ### 47. A nurse is assessing a client who was in a motor vehicle accident and suspects a tension pneumothorax. Which of the following clinical findings support this diagnosis? A. Tracheal deviation away from the affected side and hypotension B. Bilateral equal breath sounds and tachycardia C. Productive cough with yellow sputum and dull lung percussion D. Bradycardia and increased tactile fremitus over the affected lung ### 48. A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following conditions is the most common cause of ARDS? A. Sepsis B. Alcohol use disorder C. Aspiration of gastric contents D. Pneumonia ### 49. A nurse is providing discharge teaching to a client about acetaminophen (Tylenol) use. Which statement by the nurse indicates the need for further teaching? A. “You can take up to 5,000 mg of acetaminophen per day safely.” B. “You should avoid alcohol while taking acetaminophen to prevent liver damage.” C. “It’s important to monitor your liver function tests if you take acetaminophen regularly.” D. “If you experience nausea, jaundice, or dark urine, you should notify your provider immediately.” ### 50. A nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client is receiving mechanical ventilation with a high fraction of inspired oxygen (FiO₂), but oxygen saturation remains low. Which intervention should the nurse anticipate to improve oxygenation? A. Position the client in a prone position B. Increase the tidal volume on the ventilator C. Encourage incentive spirometry every hour D. Administer high doses of opioids for comfort ### 51. A nurse is assessing a client with a suspected pleural effusion. Which of the following assessment findings would indicate a pleural effusion? A. Diminished breath sounds on the affected side B. Clear lung sounds on both sides C. Increased tactile fremitus on the affected side D. Hyperresonant percussion note on the affected side ### 52. A nurse is caring for a patient with a pneumothorax and a chest tube. Which of the following tasks is appropriate to delegate to an LPN? A. Administering pain medication as prescribed. B. Assessing the patient's respiratory status and documenting findings. C. Changing the chest tube drainage system. D. Teaching the patient about the purpose of the chest tube. ### 53. A nurse has been assigned to check the emergency crash cart on the unit. Which is a correct step for this process? A. Verify that all supplies and medications are within their expiration dates. B. Restock the cart with extra supplies that may be needed during the shift. C. Perform a detailed inspection of the cart once a week. D. Check the cart only if it does not interfere with patient care. ### 54. The nurse is caring for a patient who was given succinylcholine for intubation. The patient develops a spike in temperature and muscle rigidity. Which medication would the nurse prepare to administer? A. Dantrolene B. Flumazenil C. Rocuronium D. Neostigmine ### 55. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave ### 56. The nurse is monitoring a telemetry strip showing the following rhythm with regular wide QRS complexes without visible P waves, occurring at a rate of 180/min. The patient is unresponsive and pulseless. Which action should the nurse take first? A. Begin CPR B. Defibrillate the patient C. Prepare for synchronized cardioversion D. Administer amiodarone IV push ### 57. The nurse is monitoring a telemetry strip showing regular wide QRS complexes without visible P waves, occurring at a rate of 180/min. The patient is unresponsive and pulseless. What rate would report to the doctor? A. Ventricular Tachycardia B. Normal Sinus Rhythm C. Atrial Fibrillation D. Asystole For the remaining items, the report identifies the question type but **does not display the individual answer choices**, so I am listing the question stems only. ### 58. Identify the client's condition, the appropriate action to take, and the parameters to monitor. Complete the diagram by dragging the options from below. ### 59. A nurse is caring for a client who has been mechanically ventilated for 72 hours due to acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse implement to prevent complications associated with mechanical ventilation? **(Select all that apply.)** ### 60. The nurse is caring for a client with a post-insertion of a chest tube. Which of the following interventions are appropriate for this client? ### 61. A nurse is caring for a client who has just been intubated with an endotracheal tube. The nurse is verifying the placement of the tube. Which of the following methods are the most reliable and accurate for confirming the correct placement of the endotracheal tube? ### 62. A nurse is caring for a client who is mechanically vented with an endotracheal tube. Select which of the following interventions are appropriate. ### 63. Complete the following diagram using the options provided. Choose the priority client condition. ### 64. A charge nurse in the intensive care unit (ICU) is informed that the hospital is activating its disaster response plan due to a mass casualty incident. Which actions should the nurse take to prepare for the influx of critically ill clients? **(Select all that apply.)** ### 65. A nurse is preparing to prevent airway complications in a client post-extubation. Which of the following interventions are appropriate? **(Select all that apply.)** ### 66. A nurse is implementing care for a mechanically ventilated client to prevent ventilator-associated pneumonia (VAP). For each intervention below, select whether it is Recommended or Contraindicated for preventing VAP. ### 67. A nurse is caring for a mechanically ventilated client in the ICU. Which of the following interventions should the nurse implement to prevent both ventilator-associated pneumonia (VAP) and pressure ulcers? **(Select all that apply.)** ### 68. A nurse is caring for a mechanically ventilated patient receiving gastrostomy tube (GT) feedings. For each intervention below, select whether it is Recommended, Not Recommended, or Contraindicated to promote safety and prevent complications. ### 69. You are the triage nurse in the emergency department. Based on the emergency triage system, which of the following clients should be categorized as emergent, requiring immediate intervention? **(Select all that apply.)** ### 70. A nurse is assessing a client with suspected pleural effusion. Which of the following clinical manifestations should the nurse expect to find? **(Select all that apply.)** ### 71. A nurse is monitoring a client who just underwent a thoracentesis for pleural effusion. Which of the following findings would indicate a potential complication of the procedure? **(Select all that apply.)** ### 72. A 72-year-old male client is admitted to the hospital with fever, chills, productive cough, and pleuritic chest pain. His daughter reports that he has been feeling weak for the past few days and has refused to eat. Assessment findings include temperature 101.5°F (38.6°C), HR 112 bpm, RR 24 breaths/min, BP 102/64 mmHg, SpO₂ 89% on room air, crackles and diminished breath sounds in the right lower lobe, dullness over the right lung base, pale and diaphoretic skin, thick yellow-green sputum, and slight confusion. A chest X-ray confirms right lower lobe pneumonia. Based on the client's presentation, which assessment findings are consistent with pneumonia? **(Select all that apply.)** ### 73. Click the findings below that require follow up. ### 74. Complete the following sentence using the options provided. ### 75. Complete the following sentences using the list of options provided. ### 76. Identify whether the order or intervention is anticipated or contraindicated. ### 77. Complete the following sentences using the options provided. ### 78. After the nurse has performed the appropriate interventions, which of the following findings would suggest that the client's status is deteriorating?