ATI CRITICAL THINKING FOR ATI PROCTORED EXAM ACTUAL
EXAM 250 QUESTIONS AND CORRECT DETAILED ANSWERS
The nurse is assisting with caring for a client who will receive a unit of blood. Just
before the infusion, it is most important for the nurse to check which item? -
ANSWER: Vital signs
A client who is receiving a blood transfusion pushes the call light for the nurse. When
entering the room, the nurse notes that the client is flushed, dyspneic, and
complaining of generalized itching. How should the nurse correctly interpret these
findings? - ANSWER: Transfusion reaction
A client who was receiving a blood transfusion has experienced a transfusion
reaction. The nurse sends the blood bag that was used for the client to which area? -
ANSWER: The blood bank
The nurse takes a client's temperature before giving a blood transfusion. The
temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered
nurse (RN) and anticipates that which action will take place? - ANSWER: The blood
will be held, and the primary health care provider (PHCP) will be notified.
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site.
The nurse notes that the site is cool, pale, and swollen and that the IV has stopped
running. The nurse determines that which has probably occurred? - ANSWER:
Infiltration
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The
nurse notes the site to be reddened, warm, painful, and slightly edematous in the
area of the vein proximal to the IV catheter. The nurse interprets that this is likely
the result of which? - ANSWER: Phlebitis of the vein
The nurse has been instructed to remove an intravenous (IV) line. The nurse
removes the catheter by withdrawing the catheter while applying pressure to the
site with which item? - ANSWER: Sterile 2 × 2 gauze
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The
nurse understands that it is necessary to remain with the client for what time period
after the transfusion is started? - ANSWER: 15 minutes
The nurse is assisting with caring for a client who is receiving a unit of packed red
blood cells (PRBCs). The nurse should tell the client that it is most important to
report which sign(s) immediately? - ANSWER: Chills, itching, or rash
The nurse is assisting with caring for a client who has received a transfusion of
platelets. The nurse determines that the client is benefiting most from this therapy if
, the client exhibits which finding? - ANSWER: A decrease in oozing from puncture
sites and gums
A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has
just ingested liquid furniture polish. Which action should the nurse instruct the
mother to take first? - ANSWER: Call the poison control center.
The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If
the client progresses from preeclampsia to eclampsia, the nurse should take which
action first? - ANSWER: Clear and maintain an open airway.
The nurse is assisting with caring for a client with abruptio placentae. While caring
for the client, the nurse notes that the client begins to develop signs of shock. The
nurse should take which action first? - ANSWER: Turn the client onto her side.
A woman in active labor has contractions every 2 to 3 minutes that last for 45
seconds. The fetal heart rate between contractions is 100 beats per minute. On the
basis of these findings which is the priority nursing action? - ANSWER: Notify the
registered nurse (RN) immediately.
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The
client suddenly complains of chest pain and dyspnea. The nurse should initially check
which item? - ANSWER: Vital signs
The nurse suspects that the client has a pulmonary embolism. Which is the most
important nursing action? - ANSWER: Administer oxygen by face mask, as
prescribed.
The nurse notes that the 4-hour postpartum client has cool, clammy skin and that
she is restless and excessively thirsty. The nurse immediately notifies the registered
nurse and then performs which action? - ANSWER: Checks the vital signs
The nurse in the newborn nursery receives a telephone call to prepare for the
admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4.
When planning for the admission of this infant, which is the nurse's highest priority?
- ANSWER: Connecting the resuscitation bag to the oxygen outlet
A child is brought to the emergency room and the mother reports that the child
accidentally swallowed paint thinner after mistaking it for water. The nurse should
perform which action first? - ANSWER: Check the circulation, airway, and breathing
status of the child.
A 4-year-old child sustains a fall at home injuring the right arm and is brought to the
emergency department by the mother. The nurse should perform which emergency
actions in the care of the child? Select all that apply. - ANSWER: Elevate the right
arm.
Check the neurovascular status of the right extremity
EXAM 250 QUESTIONS AND CORRECT DETAILED ANSWERS
The nurse is assisting with caring for a client who will receive a unit of blood. Just
before the infusion, it is most important for the nurse to check which item? -
ANSWER: Vital signs
A client who is receiving a blood transfusion pushes the call light for the nurse. When
entering the room, the nurse notes that the client is flushed, dyspneic, and
complaining of generalized itching. How should the nurse correctly interpret these
findings? - ANSWER: Transfusion reaction
A client who was receiving a blood transfusion has experienced a transfusion
reaction. The nurse sends the blood bag that was used for the client to which area? -
ANSWER: The blood bank
The nurse takes a client's temperature before giving a blood transfusion. The
temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered
nurse (RN) and anticipates that which action will take place? - ANSWER: The blood
will be held, and the primary health care provider (PHCP) will be notified.
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site.
The nurse notes that the site is cool, pale, and swollen and that the IV has stopped
running. The nurse determines that which has probably occurred? - ANSWER:
Infiltration
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The
nurse notes the site to be reddened, warm, painful, and slightly edematous in the
area of the vein proximal to the IV catheter. The nurse interprets that this is likely
the result of which? - ANSWER: Phlebitis of the vein
The nurse has been instructed to remove an intravenous (IV) line. The nurse
removes the catheter by withdrawing the catheter while applying pressure to the
site with which item? - ANSWER: Sterile 2 × 2 gauze
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The
nurse understands that it is necessary to remain with the client for what time period
after the transfusion is started? - ANSWER: 15 minutes
The nurse is assisting with caring for a client who is receiving a unit of packed red
blood cells (PRBCs). The nurse should tell the client that it is most important to
report which sign(s) immediately? - ANSWER: Chills, itching, or rash
The nurse is assisting with caring for a client who has received a transfusion of
platelets. The nurse determines that the client is benefiting most from this therapy if
, the client exhibits which finding? - ANSWER: A decrease in oozing from puncture
sites and gums
A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has
just ingested liquid furniture polish. Which action should the nurse instruct the
mother to take first? - ANSWER: Call the poison control center.
The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If
the client progresses from preeclampsia to eclampsia, the nurse should take which
action first? - ANSWER: Clear and maintain an open airway.
The nurse is assisting with caring for a client with abruptio placentae. While caring
for the client, the nurse notes that the client begins to develop signs of shock. The
nurse should take which action first? - ANSWER: Turn the client onto her side.
A woman in active labor has contractions every 2 to 3 minutes that last for 45
seconds. The fetal heart rate between contractions is 100 beats per minute. On the
basis of these findings which is the priority nursing action? - ANSWER: Notify the
registered nurse (RN) immediately.
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The
client suddenly complains of chest pain and dyspnea. The nurse should initially check
which item? - ANSWER: Vital signs
The nurse suspects that the client has a pulmonary embolism. Which is the most
important nursing action? - ANSWER: Administer oxygen by face mask, as
prescribed.
The nurse notes that the 4-hour postpartum client has cool, clammy skin and that
she is restless and excessively thirsty. The nurse immediately notifies the registered
nurse and then performs which action? - ANSWER: Checks the vital signs
The nurse in the newborn nursery receives a telephone call to prepare for the
admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4.
When planning for the admission of this infant, which is the nurse's highest priority?
- ANSWER: Connecting the resuscitation bag to the oxygen outlet
A child is brought to the emergency room and the mother reports that the child
accidentally swallowed paint thinner after mistaking it for water. The nurse should
perform which action first? - ANSWER: Check the circulation, airway, and breathing
status of the child.
A 4-year-old child sustains a fall at home injuring the right arm and is brought to the
emergency department by the mother. The nurse should perform which emergency
actions in the care of the child? Select all that apply. - ANSWER: Elevate the right
arm.
Check the neurovascular status of the right extremity
