ATI Virtual-ATI NCLEX-RN Comprehensive Predictor Practice
Questions & Exam Prep | Virtual ATI Green Light Review, ATI
Comprehensive Predictor, NCLEX-RN Practice Test, Clinical
Judgment, NGN-Style Questions, Management of Care, Safety
& Infection Control, Health Promotion, Psychosocial Integrity,
Pharmacological Therapies, Reduction of Risk Potential,
Physiological Adaptation, Prioritization, Delegation,
Leadership, Nursing Fundamentals, Adult Medical-Surgical,
Maternal-Newborn, Pediatrics, Mental Health, Pharmacology
& Detailed Rationales
Question 1: A nurse is reinforcing teaching with a client who has a
new prescription for a metered-dose inhaler (MDI) with a spacer.
Which of the following actions by the client indicates an
understanding of the teaching?
A. Inhales rapidly upon actuation of the MDI
B. Holds the breath for 10 seconds after inhaling the medication
C. Places the spacer in the mouth before actuating the MDI
D. Activates the MDI before placing the spacer in the mouth
CORRECT ANSWER: B. Holds the breath for 10 seconds after
inhaling the medication
Rationale: Holding the breath for 5 to 10 seconds after inhaling allows for
maximum deposition of the aerosolized medication in the lungs. Inhaling
rapidly can cause the medication to impact the oropharynx rather than
reaching the lower airways. The spacer should be placed in the mouth first,
followed by actuation of the MDI .
Question 2: A charge nurse is observing a newly licensed nurse
perform a sterile dressing change. Which of the following actions
should the charge nurse identify as a breach of sterile technique?
A. Opens the sterile package away from the body
B. Holds sterile objects above the waist
C. Places the sterile field within 2.5 cm (1 in) of the edge of the table
D. Sets up the sterile field before applying sterile gloves
CORRECT ANSWER: C. Places the sterile field within 2.5 cm (1 in)
of the edge of the table
,Rationale: A sterile field must be at least 2.5 cm (1 inch) from the edge of
the table, as the edges are considered unsterile. Opening the package away
from the body, holding objects above the waist, and setting up the field
before gloving are all appropriate sterile techniques .
Question 3: A nurse is monitoring a client who is receiving a blood
transfusion. Which of the following findings indicates a hemolytic
transfusion reaction?
A. Flank pain and chills
B. Hypertension and bradycardia
C. Urticaria and wheezing
D. Fever and hypotension
CORRECT ANSWER: A. Flank pain and chills
Rationale: Hemolytic transfusion reactions occur when the recipient's
antibodies attack the donor's red blood cells. Manifestations include low
back/flank pain, chills, fever, tachycardia, tachypnea, hypotension, and
hemoglobinuria. Urticaria and wheezing are signs of an allergic reaction
rather than a hemolytic reaction .
Question 4: A nurse is caring for a client with a new diagnosis of
type 1 diabetes mellitus. Which of the following statements by the
client indicates a need for further teaching regarding foot care?
A. "I will trim my toenails straight across."
B. "I will soak my feet in hot water daily."
C. "I will apply lotion to my feet but not between my toes."
D. "I will wear white cotton socks."
CORRECT ANSWER: B. "I will soak my feet in hot water daily."
Rationale: Clients with diabetes should not soak their feet in hot water due
to the risk of burns from decreased sensation. They should test water
temperature with their elbow. Trimming nails straight across, applying
lotion (avoiding between toes), and wearing white cotton socks are
appropriate foot care practices .
Question 5: A nurse is preparing to administer a continuous enteral
feeding via a nasogastric tube. Which of the following actions
should the nurse take first?
,A. Elevate the head of the bed to 30 degrees
B. Verify tube placement by aspirating gastric contents
C. Flush the tube with 30 mL of water
D. Connect the feeding bag to the tubing
CORRECT ANSWER: B. Verify tube placement by aspirating gastric
contents
Rationale: The first action is to verify tube placement to prevent aspiration
and ensure the feeding goes into the stomach. Elevating the head of the bed
is important but is done after verifying placement. Flushing and connecting
the feeding bag follow placement verification .
Question 6: A nurse is assessing a client who is 2 days
postoperative following a total hip arthroplasty. The nurse
observes that the client's surgical dressing has a 5 cm area of bright
red drainage. Which of the following actions should the nurse take
first?
A. Notify the surgeon immediately.
B. Reinforce the dressing with sterile gauze.
C. Mark the perimeter of the drainage on the dressing.
D. Change the dressing completely.
CORRECT ANSWER: C. Mark the perimeter of the drainage on the
dressing.
Rationale: Marking the drainage allows the healthcare team to objectively
monitor for ongoing or increased bleeding without disrupting the surgical
site or introducing infection. Complete dressing changes or immediate
notifications are typically reserved for excessive, rapidly expanding, or foul-
smelling drainage .
Question 7: A nurse is caring for a client who has a nasogastric tube
set to low intermittent suction. Which of the following findings
indicates that the tube is functioning properly?
A. The client reports persistent nausea.
B. The pH of the aspirated gastric fluid is 7.5.
C. The client's abdomen is soft and non-distended.
D. There is continuous bubbling in the suction canister.
, CORRECT ANSWER: C. The client's abdomen is soft and non-
distended.
Rationale: A soft, non-distended abdomen indicates effective gastric
decompression. Nausea suggests poor function, a pH of 7.5 is too alkaline
for gastric contents, and continuous bubbling in the canister is not expected
with low intermittent suction .
Question 8: A nurse is reviewing the laboratory results of a client
who has chronic kidney disease. Which of the following values
requires the most immediate intervention?
A. Serum potassium 5.8 mEq/L
B. Serum sodium 135 mEq/L
C. Hemoglobin 9.2 g/dL
D. Blood urea nitrogen 38 mg/dL
CORRECT ANSWER: A. Serum potassium 5.8 mEq/L
Rationale: Hyperkalemia (potassium >5.0 mEq/L) in a client with chronic
kidney disease poses a high risk for life-threatening cardiac dysrhythmias
and requires immediate intervention. The other values are abnormal but
not immediately life-threatening .
Question 9: A nurse is teaching a client who has type 2 diabetes
mellitus about foot care. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I will soak my feet in warm water for 20 minutes daily."
B. "I will trim my toenails straight across."
C. "I will apply lotion between my toes to prevent dryness."
D. "I will walk barefoot only inside my home."
CORRECT ANSWER: B. "I will trim my toenails straight across."
Rationale: Trimming toenails straight across prevents ingrown nails and
reduces the risk of skin breakdown. Soaking feet, applying lotion between
toes, and walking barefoot all increase the risk of maceration, infection, or
injury in diabetic clients .
Question 10: A nurse is preparing to administer a blood transfusion
to a client. Which of the following actions is the highest priority
before initiating the transfusion?