ATI NCLEX Exam Review Questions and Rationales 100% Graded 2023

ATI NCLEX Exam Review Questions and Rationales 100% Graded 2023 List the pertinent information that should be included in a transfer report. *** Medical diagnosis, care providers, demographic information, overview of health status, plan of care, recent progress, alterations in health status that cause immediate concern, notifications of assessments or care within the next few hours, recent vitals and medications (scheduled and PRN), allergies, diet and activity orders, specific equipment or adaptive devices, advance directives, emergency code status, family involvement in healthcare, and healthcare proxy if applicable. What are three (3) of the provider's responsibility for obtaining an informed consent? *** The provider must make sure that the patient understands the reason for the treatment or procedure, how the treatment or procedure will benefit the patient, and the risks involved if the patient chooses not to receive the treatment or procedure. The physician should also discuss alternatives to care if they chose to not have the procedure done. Identify three (3) priority teaching points to include when educating a client to use a cane. *** Maintain two points of support on the ground at all times, keep the cane on the stronger side of the body, move the cane forward about 6-10 inches and then move the weaker leg toward the cane before advancing the stronger leg past the cane. The nurse is teaching a new parent appropriate finger foods to introduce around nine (9) months. Identify five (5) finger foods that would be appropriate to introduce at nine (9) months. *** Ripe bananas, graham crackers, noodles, pears, peaches How should the nurse respond when the client requests information about meditation? *** Meditation uses rhythmic breathing to calm the mind and the body. A client is at risk for a deep vein thrombosis. What is the priority assessment for this client? Describe the procedure to use when applying elastic stockings (TEDS). *** Perform hand hygiene. Assess skin, circulation, leg edema. Measure calf/thigh circumference and the length of the leg to select correct TEDS size. Turn the stockings inside to the heel, place on the foot, pull the remainder of the stocking over the heel and on the leg, smoothing any creases or wrinkles. Remove every 8H to assess for redness, warmth, tenderness. Keep clean/dry. Document presence of TEDS. A client has been prescribed a mechanical soft diet. What are three (3) indications for this therapeutic diet? *** Mechanical soft diet includes clear and full liquids plus diced and ground foods, indicated by trouble chewing/swallowing, difficulty moving or loss of feeling in areas of the mouth, or surgery in the mouth. The nurse has been assigned to a post-abdominal surgery client who has also been diagnosed with dementia. The family is concerned about pain control for the client because the client is confused. What should the nurse include in their teaching to the family about the pain control plan for this client? *** Vital signs are indicative of pain, therefore assessed frequently. Explain behavioral changes due to the dementia which may indicate pain. Pre-medicate the patient prior to activities and before pain is expected. It is important for the family to understand that there are pain scales that can be used to help determine if pain medication is needed. A client reports difficulty falling asleep. What are nursing interventions to promote sleep? *** Promote a bedtime routine, exercise at least 2H before bedtime, personal hygiene needs to promote comfort, muscle relaxation if anxious/stressed A nurse is conducting an admission assessment for an older adult client with a hearing impairment. What are some strategies the nurse can use to improve communication with this client? *** Face the patient and speak slower in a normal volume, do not approach the patient from behind, make sure the patient is aware you are speaking before you initiate conversation. The physician prescribes meperidine 25 mg IM now for a client's pain. Available: Meperidine 100 mg/mL How much meperidine will the nurse administer? *** 25 mg * 1mL/100mg = 0.25mL Identify three (3) manifestations of late hypoxemia. *** Confusion, cyanosis, bradypnea, bradycardia, hypotension, cardiac dysrhythmias What may an elderly client complain of when experiencing decreased cardiac output and decreased contraction strength? *** Anxiety, restlessness, dyspnea, orthopnea, change in LOC, decreased activity, clammy skin, edema, weight gain, decreased urinary output. What questions should a nurse ask when obtaining a health history for a client with a history of chest pain and dyspnea? *** Frequency or intensity of the pain and if it radiates to another area, any exacerbating events, if anything makes it better/worse, how long the pain/SOB lasts, and if anything helps to reduce the dyspnea. A client's lab values indicate a serum sodium level of 150 mEq/L. How could this affect the client's vital signs? *** Hypernatremia - hyperreflexia, seizures, coma, confusion, increased HR and BP A nurse is teaching a caregiver about the use of a vacuum-assisted closure system. How should the nurse instruct the caregiver to apply the foam strips? *** Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing is placed for a negative pressure (suction) to occur once the tubing is connected to the systems therapy unit. What class of medication is amitriptyline and why is this medication used as an adjuvant medication for pain? *** Amitriptyline (Elavil) Class: Tricyclic antidepressant Use: Indicated for chronic pain syndromes (fibromyalgia, neuropathic pain, headache, lower back pain) The adjuvant medication is used to help the opiod work. A nurse is caring for a client with asthma who asks if montelukast sodium can be taken for acute asthma symptoms. When should montelukast sodium be taken? *** Daily at bedtime, and 2 hours before exercise for exercise induced bronchospasms. A client has a new prescription for salmeterol. The nurse is teaching the client about adverse effects of the medication. What instructions should the nurse include in thus education? *** Salmeterol SE - headache, heart palpitations, tachycardia, abdominal pain, diarrhea, nausea, soreness, muscle cramps, trembling, paradoxical bronchospasm, cough Clients taking salmeterol should be taught to take their pulse daily and report an increase in 20 bpm. A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler. What instructions should the nurse include concerning use of these inhalers? *** Administer albuterol first, as albuterol enhances glucocorticoid absorption, therefore enhancing the beclomethasone absorption. A nurse is administering gemfibrozil to a client with elevated cholesterol. Identify two (2) adverse effects related to this medication. *** Gemfibrozil SE - abdominal discomfort, myopathy A nurse is providing instructions to a client who has a prescription for methotrexate. What should the nurse include in the client education? *** Teach the patient to watch for coffee-ground emesis/black tarry stools which may indicate a GI bleed (notify HCP in the occurrence of these symptoms), watch for mouth sores, perform frequent oral hygiene, do not become pregnant while taking this medication, encourage increased fluid intake, teach the patient they will require labs to be drawn while on this med. A nurse is preparing to educate a client with diabetes who has a new prescription for metformin. What should the nurse included in the client instructions? *** Contraindications: Severe infection, shock, hypoxic conditions, alcohol use disorders. Avoid during pregnancy (Pregnancy Risk Category B). Do not use iodine-containing contrast medias. Pt. Teaching: Take immediate-release tablets 2x/day with breakfast and dinner. Take sustained-release tablets once/day with dinner. Metformin SE: GI disturbances (anorexia, nausea, diarrhea, weight loss), Vitamin B12 and Folic Acid deficiency, Lactic acidosis (hyperventilation, myalgia, sluggishness, somnolence) A nurse has provided education to a client who has a new prescription for exenatide. What statements by the client would indicate they understand the instructions? *** "I should give exenatide injection within 60 mins before the morning and evening meals, never to be administered after a meal. I should administer oral medications 1H before injecting exenatide. Or I could use the longer-acting formula which can be administered once weekly." A nurse has provided education to a client who has a new prescription for brimonidine ophthalmic drops. What statements by the client would indicate they understand the instructions? *** "Brimonidine decreases production and can also increase outflow of aqueous humor to lower IOP. I should use caution with driving and other tasks, inform the provider of dizziness/weakness. I should remove contact lenses before administering, and delay insertion of the lens at least 15 mins after administration to prevent absorption of the medication into the lens." A nurse is caring for a client who has a new prescription for alosetron. What are the expected therapeutic effects of this medication? *** Alosetron MoA/Use: selective blockade of serotonin receptors, which innervate the viscera and result in increased firmness in stool and decrease in urgency/frequency of defecation. This med is approved only for female clients who have severe IBS-D that has lasted more than 6 months and has been resistant to conventional management. An oncology client is prescribed filgrastim. What are the indications for this therapy? *** Filgrastim (Neupogen) Indications: Prevention of febrile neutropenia, reduction of time for neutrophil recovery and duration of fever in patients undergoing chemotherapy, mobilization of hematopoietic progenitor plantation, management of chronic severe neutropenia A critical care client is in need of adenosine. What is the indication of this medication and how is this medication administered? *** Adenosine (Adenocard) Indications: paroxysmal supraventricular tarchycardia Administer via IV bolus, flushed with saline after administration. The client has been ordered ranitidine. List three (3) teaching points to discuss with the client prior to the first administration. *** Ranitidine Pt. Teaching: Take medication as directed for the full course of the therapy, take missed doses as soon as remembered but not if almost time for next dose, do not double doses. A client with an upper respiratory infection is prescribed guaifenesin. Identify two (2) teaching points to discuss with the client prior to administering this medication. *** Guaifenesin Pt. Teaching: Do not crush, report cough longer than 1 week, increase fluid intake The client with Klebsiella in the urine is ordered the medication ciprofloxacin. Identify three (3) complications associated with this medication the client can develop with administration of this medication. *** Ciprofloxacin SE: GI discomfort (Nausea, vomiting, diarrhea), Achilles tendon rupture, suprainfection (thrush, vaginal yeast infection), phototoxicity (severe sunburn) A nurse is caring for a client following an infratentorial craniotomy. How should the nurse position this client in the immediate post-operative period? *** Supine on their side. Turn Q2H for 24-48H. A nurse is caring for a client following a bone marrow biopsy. What information should the nurse include in the discharge education? *** Report excess bleeding, signs of infection, check site daily, apply ice to site to prevent bleeding, avoid aspirin, return in 7-10 days to remove sutures. What are three (3) risk factors for testicular cancer? List three (3) subjective and objective findings in the client with testicular cancer? *** Risk Factors: HIV infection, undescended testes, genetic disposition, metastasis of another cancer, and age 20-54. Subjective: feeling of heaviness in the testicles, lump in the testes, painless testes Objective: change in bowel/bladder habits, change in warts/moles, unusual bleeding/discharge A nurse is providing education regarding risk factors for gout. What information should be provided? *** Gout Risk Factors: cardiovascular disease, alcohol substance disorder, diuretic use, obesity, chemotherapy agents, chronic kidney failure, trauma, starvation dieting A nurse is caring for a client with chronic gastritis. Provide three (3) dietary recommendations the nurse should include in client education? *** Frequent meals, avoiding coffee, alcohol, or foods causing GI irritation. Chew slowly. A nurse is caring for a client who has been admitted with renal calculi. List three (3) interventions the nurse will take in the management of renal calculi. *** Report labs/diagnostics to HCP, provide pre-operative and post-operative care per indications, monitor pain/I&Os/urinary pH When a client has renal calculi, the nurse will need to strain the urine for the passage of the stone. This should be the first intervention to occur. A nurse is caring for a client with Rheumatoid arthritis who is prescribed a non-steroidal anti-inflammatory drug (NSAID) for the treatment of joint pain. Provide three (3) teaching points in client education the nurse should provide regarding this medication therapy. *** Take meds with food/full glass of water or milk. Watch for GI bleeding (coffee ground, emesis, black tarry stools). Avoid alcohol consumption. A nurse is caring for a client with colorectal cancer who is scheduled for a colectomy. What preoperative and post-operative education should be provided to this client? *** Pre-Operative Education: Clear liquids several days before the surgery due to the die, complete bowel preparation per prescription, administer antibiotics to eradicate intestinal flora. Post-Operative Education: Deep breathing, turning, incision activity limits, ostomy care, management of post-operative complications (incontinence, sexual dysfunction, etc.) A nurse is caring for a client following a colposcopy with cervical biopsy. What post-procedure information should be provided? *** Rest for the first 24H post-procedure, abstain from sexual intercourse, avoid douching or applying vaginal creams or tampons until all discharge has stopped, avoid lifting heavy objects for 2 weeks A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this disease process. *** Hyperkalemia, hypercalcemia, hyponatremia, hypoglycemia, decreased cortisol levels, increased BUN/Creatinine A client with peripheral vascular disease had a below the knee amputation three months ago. The client now complains of phantom limb pain. List three (3) interventions to address the pain associated with this condition. *** Administer beta blockers (propranolol) which may relieve dull or burning sensations, administer antiepileptics (gabapentin, carbamazepine) to relieve sharp, stabbing sensations, alternative treatment such as massage/heat therapy or relaxation therapy. A nurse is caring for a client undergoing a clonidine suppresstion test to identify a pheochromocytoma. If a client has a pheochromocytoma and is administered clonidine, what will the outcome be? *** No effect, clonidine will not decrease BP A mass casualty event has occurred and a nurse is responsible for client triage. What categories should the nurse use and what do these mean? (Review the Nursing Leadership Review Module) *** Emergent category (class 1) - highest priority given to pt. with life-threatening injuries, high possibility of survival once stabilized Urgent category (class 2) - second-highest priority given to pt. who have major injuries which are not yet life-threatening and can wait 45-60mins for treatment Non-urgent category (class 3) - third-highest priority given to pt. who have minor injuries which are not life threatening and do not require immediate treatment Expectant category (class 4) - lowest priority given to pt. who are not expected to live and will be allowed to die naturally, comfort measures may be provided, but no restorative care What are some common complications related to internal pacemaker insertion? *** Infection/hematoma at the insertion site, pneumothorax, hemothorax, arrhythmias, improper sensing or pacing electrical charge being outside the heart A nurse is caring for a client with a tension pneumothorax. What is a tension pneumothorax and what manifestations should the nurse expect? *** Tension Pneumothorax - air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration, caused by trauma usually S&S - anxiety, pleuritic pain, respiratory distress, tracheal deviation to the unaffected side, reduced or absent breath sounds on affected side, asymmetrical chest expansion, hyperresonance on percussion, subcutaneous emphysema What is VEAL CHOP? *** - acronym for FHR accelerations/decelerations and their causes Variable = Cord compression Early = Head compression Acceleration = Okay Late = Placental insufficiency What is BUBBLE HE? *** - Maternal postpartum assessment Breast size, shape, engorgement Uterus - firm/boggy Bladder - tender/distended Bowel movement Lochia - amount, odor, color, clots Episiotomy location, stiches, edema, redness Homan's sign - positive? (+ Homan's sign is indicative of a DVT; pt. leg positioned at a 90* angle either while in supine or sitting position, dorsiflexion of the foot reveals pain in the calf if +; other S&S of DVT = redness, sudden, sharp pain, leg warmth) Emotional status, bonding with baby What are the potential Rh issues in pregnancy? *** Mother is Rh negative, baby is Rh positive = problem Administer Rhogam if mother is Rh negative, regardless of father's Rh compatibility. Assume the baby may be Rh positive regardless. Always admin Rhogam for any future pregnancy. Administer Rhogam between 26-18 weeks of pregnancy, and 72 hours postpartum if baby is Rh positive at birth. A nurse is caring for a client scheduled for a chorionic villus sampling (CVS) procedure. What client education should the nurse provide prior to the procedure? Identify potential complications associated with CVS. *** Client Education - CVS is an assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under U/S guidance. This is a 1st trimester alternative to amniocentesis. Advantage is an earlier diagnosis of any abnormalities. Performed at 10-13 wks gestation. Complications involve spontaneous abortion (higher than amniocentesis risk), fetal limb loss (greatest risk prior to 9wks gestation), miscarriage, chorioamnionitis, rupture of membranes. A nurse is providing community education regarding risk factors for ovarian cancer. Identify five (5) risk factors associated with the development of ovarian cancer. (Review the Med Surg RM) *** Ovarian Cancer Risk Factors - obesity, full term pregnancy after 35 y.o. or never having carried a pregnancy to term, fertility drug use, hormone replacement therapy, family history of ovarian/breast/colorectal cancer A nurse is caring for a client who is considering use of a hormonal intrauterine system. What information regarding the advantages of an Intrauterine Device (IUD) should the nurse provide? *** IUD Advantages - Effective for 1-10years (3-5 if hormonal), can be inserted after childbirth/miscarriage/abortion, can be removed easily & have no effect on fertility post-removal, safe for breastfeeding mothers, hormonal IUDs may lessen bleeding/cramping during menstruation What behaviors are observed by the nurse in the client during the latent phase of the first stage of labor? *** Latent phase, first stage of labor behaviors - talkative, eager, contractions Q15-30mins, cervical dilation 1-4cm A nurse is providing education to a new mother regarding storage of breast milk. Identify five (5) teaching points to discuss with the new mother regarding storage of breast milk. *** Breastmilk storage - store at room temperature for up to 8H, refrigerate in sterile bottles for use in 8days, frozen in sterile containers up to 6mo, store in a deep freezer for 12mo., thaw milk in the refrigerator for 24H A nurse is providing care for an uncircumcised male newborn and his mother. What information should be provided during discharge regarding bathing of the penile area of the newborn male? *** Wash the penis with soap/water and rinse, foreskin should not be forced back or constriction may result A nurse is caring for a client in the transition phase of the first stage of labor. What interventions should the nurse include when caring for this client? *** Transition phase, first stage of labor NU Care - encourage voiding Q2H, breathing, discourage pushing until cervix is fully dilated, listen for her to indicate the need to have a bowel movement (sign the cervix is fully dilated), check pt., watch for crowning, encourage mother to bear down with contractions once fully dilated should HCP be present. What are five (5) adverse effects noted with epidural analgesia administration during labor? *** Decreased gastric emptying (N/V), inhibition of bowel/bladder elimination sensations, bradycardia/tachycardia, respiratory depression, hypotension What is an indication for taking tamoxifen? *** breast cancer What should the nurse teach the client about depot medroxyprogesterone acetate as a method of contraception? *** Come back Q12wks for another injection, receive shot in the first five days of menstruation, if given later another form of contraception should be used to help prevent pregnancy, does not protect against STDs, can increase the risk of weight gain What are the indications for prescribing hormone replacement therapy (HRT) for a menopausal client? (Review Pharmacology Module) *** Prevention of osteoporosis, relieve vasomotor symptoms (hot flashes, night sweats), or urogenital symptoms (vaginal dryness) A nurse is administering oxytocin to a client in labor. What are symptoms of uterine hyperstimulation that would cause the nurse to discontinue this medication? *** Contractions occurring >Q2mins, lasting >90secs, intensity >90mmHg, uterine resting tone >20mmHg between contractions and/or no relaxation of the uterus between contractions A nurse is caring for a client with placenta previa. What interventions should be completed for this client? *** Assess for bleeding/leakage/contractions, assess fundal height, perform Leopold maneuvers, refrain from performing vaginal exams, administer IVF, blood products & meds per order, have O2 equipment available A client at 38 weeks of gestation is admitted to Labor and Delivery for the management of preeclampsia and is placed on a magnesium sulfate IV drip. Explain the signs of magnesium toxicity for which the nurse should monitor. *** Absence of patellar DTR, UOP <30mL/H, RR <12/min, cardiac dysrhythmias, decreased LOC What education should the nurse provide to the postpartum client regarding mastitis? *** Mastitis - an infection of the breast, typically unilateral, starting about 2-4wks postpartum; painful/tender breasts with localized hard mass and reddened area usually on one breast; provide breast hygiene and proper hand hygiene to prevent mastitis; ensure a good latch by the baby The nurse is teaching the parents of an infant with tonsillitis caused by group A ß-hemolytic streptococci about the importance of compliance with antibiotic therapy. What teaching regarding this infection is important to share with the parents? *** Tonsillitis teaching - Tonsillitis is an infection of the tonsils which results in inflammation and pain. This is caused by Beta-Hemolytic Streptococci, a bacterium, and is a bacterial infection. Therefore, antibiotics must be given specific to this bacteria. The side effects of the antibiotic should be told (diarrhea, abdominal pain, etc.), and that it is important to take all prescribed medications in order to ensure the bacteria is killed off. Explain antibiotic resistance, and not to stop or miss any antibiotics even after the child starts to feel better. Complete the full course of antibiotics. A nurse is assessing for strabismus in a pediatric client. Identify three (3) clinical findings noted with strabismus. *** Strabismus - eyes point in different directions (esotropia is inward turning, exotropia is outward turning, hypertropia is upward turning, and hypotropia is downward turning), "cross-eyed" S&S - eyes may appear crossed, eye may wander when opposite eye is covered, uncoordinated eye movements, asymmetrical corneal light reflex A nurse is discussing sudden infant death syndrome (SIDS) with new parents. Identify three (3) points that the nurse should educate the parents on regarding measures to prevent SIDS. *** SIDS teaching - lie infants on back to sleep, make sure no blankets or other items in the crib, provide firm mattress, do not co-sleep, keep baby in the same room when sleeping as the parents Explain how methylphenidate hydrochloride works in children who have Attention Deficit Hyperactivity Disorder (ADHD). *** Methylphenidate hydrochloride (ADHD med) - reduces symptoms of hyperactivity and impulsive behavior, increase attention and concentration span, by increasing dopamine levels in the brain Name two (2) manifestations of infective endocarditis in children. *** Endocarditis S&S - similar to the flu, slight fever, loss of appetite, pain in muscles/joints, skin rash, headaches, fatigue, weight loss A nurse has been assigned to care for a child with hemophilia who is experiencing acute hemarthrosis. What are two (2) expected findings for this client? What are two (2) nursing interventions that can be initiated for this client? *** Hemophilia, acute hemarthrosis S&S - joint pain, stiffness, warmth, redness, loss of RoM, deformities NU interventions - administer appropriate factor replacement during bleeding episodes to treat XS bleeding (FIRST, PRIORITY), control bleeding, monitor VS (shock S&S), neuro assessment for evidence of intracranial bleed, provide prophylaxis Tx (factor VIII concentrate infusion, prior to joint bleed & 3x/week or every other day after first joint bleed), educate pt. on S&S bleeding