NUR450C| ATI With Actual Questions
& Verified Answers ,Plus Explained
Rationales/Expert Verified For
Guaranteed Pass 2026/Latest
Update/Instant Download Pdf
1. A client with chronic heart failure reports increasing shortness
of breath and a 3-pound weight gain in 24 hours. Which action
should the nurse perform first?
A. Obtain a 12-lead ECG
B. Administer prescribed furosemide now
C. Encourage the client to ambulate
D. Call the provider for new orders
B. Administer prescribed furosemide now
Rationale: Furosemide is a loop diuretic used to rapidly reduce
fluid overload and pulmonary congestion; prompt
administration is the priority for worsening HF symptoms.
2. A client with pneumonia is receiving IV ceftriaxone. The nurse
notes redness, swelling, and pain at the IV site. What is the best
immediate action?
A. Apply a warm compress to the site
B. Stop the infusion and remove the IV
C. Decrease the infusion rate and monitor
D. Flush the catheter and continue infusion
B. Stop the infusion and remove the IV
Rationale: Redness, swelling, and pain indicate phlebitis or
, extravasation; stopping and removing the IV prevents tissue
injury and infection.
3. A postoperative client has a urinary retention episode. Which
intervention should the nurse try first?
A. Insert an indwelling urinary catheter
B. Encourage the client to ambulate to the bathroom
C. Perform bladder ultrasonography (bladder scan)
D. Administer prescribed bethanechol
C. Perform bladder ultrasonography (bladder scan)
Rationale: A bladder scan noninvasively determines retention
volume and guides need for catheterization; it is the
appropriate first step.
4. A client with type 1 diabetes expresses feeling shaky and
sweaty. Blood glucose is 48 mg/dL. Which is the best next
action?
A. Give 4 oz fruit juice immediately
B. Administer regular insulin subcutaneously
C. Offer a high-fat snack like cheese and crackers
D. Call the provider for IV dextrose order
A. Give 4 oz fruit juice immediately
Rationale: For symptomatic hypoglycemia with glucose <70
mg/dL, give 15–20 g fast-acting carbohydrate (e.g., 4 oz juice)
immediately to raise glucose quickly.
5. A client with chronic kidney disease is prescribed lisinopril.
Which lab should the nurse monitor closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
, B. Serum potassium
Rationale: ACE inhibitors like lisinopril can increase serum
potassium by reducing aldosterone-mediated excretion,
risking hyperkalemia, which must be monitored.
6. A nurse is teaching fall prevention to an older adult with visual
impairment. Which intervention is most important to include?
A. Encourage wearing slippers in bed
B. Keep hallway lighting off at night
C. Place night-lights in frequently used areas
D. Advise increased fluid intake at night
C. Place night-lights in frequently used areas
Rationale: Night-lights improve visibility and reduce fall risk
during nocturnal ambulation; adequate lighting is a key
prevention strategy.
7. A client receiving heparin infusion has an aPTT of 110 seconds
(therapeutic target 60–80 sec). What should the nurse do?
A. Increase the heparin infusion rate
B. Hold infusion and notify the provider
C. Continue current infusion rate and recheck in 6 hours
D. Give protamine sulfate immediately
B. Hold infusion and notify the provider
Rationale: aPTT above therapeutic range increases bleeding
risk; hold infusion and notify provider for adjustment.
Protamine is used for significant bleeding or provider order.
8. A patient with a PCA pump is drowsy with respirations of 8/min.
What is the priority nursing action?
A. Encourage deep breathing and coughing
B. Stop the PCA pump and stimulate the client
C. Give oral naloxone to reverse effects
, D. Document findings and continue to monitor
B. Stop the PCA pump and stimulate the client
Rationale: Respiratory depression is a life-threatening sign of
opioid overdose; stop infusion and stimulate client, then
administer naloxone per protocol if needed.
9. A client with suspected meningitis is admitted. Which
precaution should the nurse implement immediately?
A. Droplet precautions with mask for 24 hours after antibiotics
B. Contact precautions until cultures return
C. Airborne precautions with N95 mask
D. Standard precautions only
A. Droplet precautions with mask for 24 hours after antibiotics
Rationale: Bacterial meningitis is spread via respiratory
droplets; droplet precautions (mask within 3 feet) should be
used until 24 hours after effective antibiotics.
10. A client is experiencing an acute panic attack in the
emergency department. Which nursing intervention is most
appropriate?
A. Leave the client alone to reduce stimulation
B. Encourage the client to take slow, deep breaths with you
C. Administer PRN haloperidol immediately
D. Provide multiple options and choices to the client
B. Encourage the client to take slow, deep breaths with you
Rationale: Guided breathing reduces hyperventilation and
anxiety. Staying with the client and using calming, simple
interventions is effective during a panic attack.
11. A patient on metoprolol reports dizziness and pulse of 48
bpm. What should the nurse do first?
A. Administer the scheduled dose of metoprolol
& Verified Answers ,Plus Explained
Rationales/Expert Verified For
Guaranteed Pass 2026/Latest
Update/Instant Download Pdf
1. A client with chronic heart failure reports increasing shortness
of breath and a 3-pound weight gain in 24 hours. Which action
should the nurse perform first?
A. Obtain a 12-lead ECG
B. Administer prescribed furosemide now
C. Encourage the client to ambulate
D. Call the provider for new orders
B. Administer prescribed furosemide now
Rationale: Furosemide is a loop diuretic used to rapidly reduce
fluid overload and pulmonary congestion; prompt
administration is the priority for worsening HF symptoms.
2. A client with pneumonia is receiving IV ceftriaxone. The nurse
notes redness, swelling, and pain at the IV site. What is the best
immediate action?
A. Apply a warm compress to the site
B. Stop the infusion and remove the IV
C. Decrease the infusion rate and monitor
D. Flush the catheter and continue infusion
B. Stop the infusion and remove the IV
Rationale: Redness, swelling, and pain indicate phlebitis or
, extravasation; stopping and removing the IV prevents tissue
injury and infection.
3. A postoperative client has a urinary retention episode. Which
intervention should the nurse try first?
A. Insert an indwelling urinary catheter
B. Encourage the client to ambulate to the bathroom
C. Perform bladder ultrasonography (bladder scan)
D. Administer prescribed bethanechol
C. Perform bladder ultrasonography (bladder scan)
Rationale: A bladder scan noninvasively determines retention
volume and guides need for catheterization; it is the
appropriate first step.
4. A client with type 1 diabetes expresses feeling shaky and
sweaty. Blood glucose is 48 mg/dL. Which is the best next
action?
A. Give 4 oz fruit juice immediately
B. Administer regular insulin subcutaneously
C. Offer a high-fat snack like cheese and crackers
D. Call the provider for IV dextrose order
A. Give 4 oz fruit juice immediately
Rationale: For symptomatic hypoglycemia with glucose <70
mg/dL, give 15–20 g fast-acting carbohydrate (e.g., 4 oz juice)
immediately to raise glucose quickly.
5. A client with chronic kidney disease is prescribed lisinopril.
Which lab should the nurse monitor closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
, B. Serum potassium
Rationale: ACE inhibitors like lisinopril can increase serum
potassium by reducing aldosterone-mediated excretion,
risking hyperkalemia, which must be monitored.
6. A nurse is teaching fall prevention to an older adult with visual
impairment. Which intervention is most important to include?
A. Encourage wearing slippers in bed
B. Keep hallway lighting off at night
C. Place night-lights in frequently used areas
D. Advise increased fluid intake at night
C. Place night-lights in frequently used areas
Rationale: Night-lights improve visibility and reduce fall risk
during nocturnal ambulation; adequate lighting is a key
prevention strategy.
7. A client receiving heparin infusion has an aPTT of 110 seconds
(therapeutic target 60–80 sec). What should the nurse do?
A. Increase the heparin infusion rate
B. Hold infusion and notify the provider
C. Continue current infusion rate and recheck in 6 hours
D. Give protamine sulfate immediately
B. Hold infusion and notify the provider
Rationale: aPTT above therapeutic range increases bleeding
risk; hold infusion and notify provider for adjustment.
Protamine is used for significant bleeding or provider order.
8. A patient with a PCA pump is drowsy with respirations of 8/min.
What is the priority nursing action?
A. Encourage deep breathing and coughing
B. Stop the PCA pump and stimulate the client
C. Give oral naloxone to reverse effects
, D. Document findings and continue to monitor
B. Stop the PCA pump and stimulate the client
Rationale: Respiratory depression is a life-threatening sign of
opioid overdose; stop infusion and stimulate client, then
administer naloxone per protocol if needed.
9. A client with suspected meningitis is admitted. Which
precaution should the nurse implement immediately?
A. Droplet precautions with mask for 24 hours after antibiotics
B. Contact precautions until cultures return
C. Airborne precautions with N95 mask
D. Standard precautions only
A. Droplet precautions with mask for 24 hours after antibiotics
Rationale: Bacterial meningitis is spread via respiratory
droplets; droplet precautions (mask within 3 feet) should be
used until 24 hours after effective antibiotics.
10. A client is experiencing an acute panic attack in the
emergency department. Which nursing intervention is most
appropriate?
A. Leave the client alone to reduce stimulation
B. Encourage the client to take slow, deep breaths with you
C. Administer PRN haloperidol immediately
D. Provide multiple options and choices to the client
B. Encourage the client to take slow, deep breaths with you
Rationale: Guided breathing reduces hyperventilation and
anxiety. Staying with the client and using calming, simple
interventions is effective during a panic attack.
11. A patient on metoprolol reports dizziness and pulse of 48
bpm. What should the nurse do first?
A. Administer the scheduled dose of metoprolol
