NURS 480 (NURS480) Exam 3 ATI Assessment | Answered Complete Performance Profile Review | Updated 2025/26.

West Coast University NURS 480 (NURS480) Exam 3 ATI Assessment | Answered Complete Performance Profile Review | Updated 2025/26. ### 1. A nurse is discussing the care of a client who has type 1 diabetes mellitus with the unlicensed assistive personnel (UAP). Which of the following situations should the nurse instruct the UAP to report immediately? A. The client refuses breakfast and requests to sleep. B. The client reports dizziness when standing. C. The client asks the AP to trim his broken toenail. D. The client reports urine that is dark yellow in color. ### 2. A nurse is teaching a newly diagnosed client with diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching? A. “I should eat more calories from complex carbohydrates than anything else.” B. “Most of my calories each day should be from fats.” C. “Simple sugars are needed more than other calorie sources.” D. “Protein should be my main source of calories.” ### 3. The nurse is starting an insulin drip to treat hyperglycemia in a diabetic ketoacidosis (DKA) client. What additional electrolyte should the nurse monitor closely? A. Potassium B. Sodium C. Calcium D. Chloride ### 4. The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse implements which of the following? A. Ask the patient to empty the bladder. B. Place the patient on NPO status. C. Assist the patient to lie flat in bed. D. Put the patient in a standing position. ### 5. A nurse is assessing a client who is receiving levothyroxine for treatment of hypothyroidism. The nurse should recognize which of the following findings is a therapeutic response to this medication? A. Increase in energy B. Decrease in appetite C. Increase in weight D. Decrease in body temperature ### 6. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient’s T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? A. Tachycardia B. Dyspnea C. Constipation D. Cold intolerance ### 7. A nurse is caring for a client who has developed agranulocytosis as a result of taking propylthiouracil (PTU) to treat hyperthyroidism. The nurse should understand that this client is at increased risk for which of the following conditions? A. Infection B. Excessive bleeding C. Ecchymosis D. Hyperglycemia ### 8. A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? A. Provide a quiet, low-stimulus environment. B. Administer aspirin as prescribed for any sign of hyperthermia. C. Keep the client NPO. D. Observe the client carefully for signs of hypocalcemia. ### 9. A patient was admitted with Addison’s disease. Assessment now reveals nausea, vomiting, and confusion. The nurse anticipates which urgent intervention? A. Administration of intravenous hydrocortisone. B. Placement of a nasogastric tube. C. Administration of intravenous diuretic. D. Immediate endotracheal intubation. ### 10. Which nursing intervention is most important for a client with diabetes insipidus? A. Monitoring strict fluid intake and output. B. Performing proper diet education. C. Assess for constipation daily. D. Measuring a fingerstick blood glucose level. ### 11. A nurse administers vasopressin to a patient who has a diagnosis of diabetes insipidus. Which of the following indicates the desired therapeutic effect? A. Urine specific gravity 1.015 B. Serum sodium 146 mEq/L C. Blood glucose 80 mg/dL D. Blood urea nitrogen (BUN) 15 mg/dL ### 12. A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? Round to the nearest whole number. ### 13. A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? A. 6.3% B. 7.8% C. 8.5% D. 10% ### 14. A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values? A. Thyroid stimulating hormone (TSH) B. Free T4 C. Serum T4 D. Serum T3 ### 15. An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed: A. Diazepam (Valium) B. Docusate (Colace) C. Ibuprofen (Motrin) D. Cefoxitin (Mefoxin) ### 16. A nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) and has a sodium level of 126 mEq/L. Which of the following nursing actions should the nurse expect to implement? A. Restrict oral fluids to 800–1,000 mL/day. B. Maintain an IV of 0.45% sodium chloride. C. Ensure the client receives a 2 g sodium diet. D. Administer desmopressin acetate (DDAVP) 0.2 mg orally. ### 17. A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client’s morning blood glucose level as 210 mg/dL instead of 120 mg/dL. Based on this error, she administered the insulin dose appropriate for a reading over 200 mg/dL before the client’s breakfast. Which of the following is the nurse’s priority action upon realizing the error? A. Monitor the client for hypoglycemia. B. Give the client 15 to 20 g of carbohydrate. C. Complete an incident report. D. Notify the nurse manager. ### 18. A nurse is providing teaching to a client who has a new diagnosis of hypothyroidism. On which of the following medications should the nurse prepare to instruct the client? A. Synthroid B. Radioactive iodine C. Sumatriptan D. Levofloxacin ### 19. A nurse finds a diabetic patient lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect? A. Hypoglycemia B. Ketoacidosis C. Myocardial infarction D. Nephropathy ### 20. The nurse has administered 4 oz of apple juice to an alert patient whose blood glucose was 48 mg/dL. Fifteen minutes later, the blood glucose is 66 mg/dL. Which action should the nurse take next? A. Give the patient 4 oz more apple juice. B. Administer PRN glucagon 1 mg IM. C. Have the patient eat some peanut butter with crackers. D. Encourage oral fluid intake. ### 21. A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? A. Expect the NPH insulin to peak in 4 to 12 hr. B. Discard the NPH solution if it appears cloudy. C. Shake the insulin vigorously before loading the syringe. D. Freeze unopened insulin vials. ### 22. A diabetic client is admitted to the emergency room with diabetic ketoacidosis (DKA). Arterial blood gases reveal pH 7.22, PaCO₂ 28 mmHg, bicarbonate 12 mEq/L. Which of the following is an appropriate analysis of the ABGs? A. Metabolic acidosis, partial compensation B. Respiratory acidosis, partial compensation C. Metabolic alkalosis, full compensation D. Respiratory alkalosis, full compensation ### 23. A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A. Inject the insulin 15 min before a meal. B. Assess for hypoglycemia 4 hr after the insulin injection. C. Monitor for polyuria. D. Administer with short-acting insulin. ### 24. The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A. The chest X-ray showed another lung cancer lesion. B. Has completed a college education. C. Has been able to stop smoking cigarettes. D. Has well-controlled type 1 diabetes mellitus. ### 25. Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? A. The patient has tan-colored stools. B. The patient’s urine is bright yellow. C. The patient has increased pain after eating. D. The patient complains of chronic heartburn. ### 26. Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? A. The patient is alert and oriented. B. The patient denies nausea or anorexia. C. The patient’s bilirubin level decreases. D. The patient has at least one stool daily. ### 27. Which finding indicates to the nurse that a patient’s transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? A. Fewer episodes of bleeding varices. B. Increased serum albumin level. C. Decreased indirect bilirubin level. D. Improved alertness and orientation. ### 28. A nurse is preparing to administer hydrocortisone sodium succinate 250 mg via IV bolus every 6 hr. Available is hydrocortisone sodium succinate 1000 mg/8 mL. How many mL should the nurse administer? Round to the nearest whole number. ### 29. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? A. Pantoprazole 80 mg IV bolus twice daily B. Pancrelipase 500 units/kg PO three times daily with meals C. Initiate a low-residue diet. D. Ambulate twice daily. ### 30. A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Increased serum amylase B. Decreased WBC C. Decreased serum lipase D. Increased serum calcium ### 31. The nurse is teaching a cirrhosis client regarding ascites management at home. Which statement indicates the patient understands the teaching? A. “I need to limit my sodium intake to 2 g/day.” B. “Fluid restriction alone provides the best control of fluid balance.” C. “I can expect to come to the hospital every other day for a paracentesis, even if my abdomen is not distended.” D. “Ammonia infusions help maintain the pressure in my veins, so the fluid isn’t in my tissues.” ### 32. A nurse is preparing to administer total parenteral nutrition (TPN) 2,592 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? Round to the nearest whole number. ### 33. Which outcome would indicate that a client with advanced cirrhosis is experiencing a serious complication? A. Frequent nosebleeds and bruising B. Elevated blood glucose C. Urinary retention D. No bowel movement in 3 days ### 34. A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first? A. Check BP, heart rate, and respirations. B. Insert a large-gauge IV catheter. C. Draw blood for coagulation studies. D. Place the patient in the supine position. ### 35. For a patient with cirrhosis, which of the following nursing actions can the registered nurse delegate to unlicensed assistive personnel (UAP)? A. Providing oral hygiene after a meal. B. Assessing the patient for jaundice. C. Palpating the abdomen for distention. D. Assisting the patient to choose the diet. ### 36. A nurse is caring for a client with cirrhosis who has a prothrombin time of 30 seconds. Which of the following medications does the nurse anticipate the provider will prescribe? A. Vitamin K B. Heparin C. Warfarin D. Ferrous sulfate ### 37. A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin D B. Vitamin B1 C. Vitamin C D. Vitamin B12 ### 38. On palpation of the liver, the client reports sharp abdominal pain. The nurse stops the exam, documents a positive Murphy’s sign and would suspect which condition? A. Cholecystitis B. Abdominal ascites C. Spleen enlargement D. Appendicitis ### 39. A nurse is caring for a client who has acute pancreatitis. After the client’s pain has been addressed, which of the following is the next intervention to include in the plan of care? A. Maintain NPO status. B. Monitor respiratory status every 8 hr. C. Encourage a side-lying position with knees flexed. D. Provide frequent oral hygiene. ### 40. The nurse is caring for a client diagnosed with hepatitis A virus. The client requests information about how the virus is transmitted. Which statement by the nurse is appropriate? A. “Most likely, you ate something that was contaminated with the virus.” B. “This virus is transmitted by sexual contact with someone who already has been infected with this virus.” C. “It is spread by blood transfusions.” D. “Have you ever injected an illegal drug?” ### 41. To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take? A. Ask the patient to extend both arms to the front. B. Request that the patient stand on one foot. C. Instruct the patient to perform the Valsalva maneuver. D. Have the patient walk a few steps with the eyes closed. ### 42. A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe client’s respiratory status. B. Elevate the head of the client’s bed 30° to 45°. C. Monitor intake and output every 8 hr. D. Check residual volume every 4 to 6 hr. ### 43. Which goal has the highest priority in the plan of care for a 26-year-old patient who was admitted with viral hepatitis, has severe anorexia and fatigue, and is homeless? A. Maintain adequate nutrition. B. Increase activity level. C. Establish a stable environment. D. Identify source of hepatitis exposure. ### 44. A client begins complaining of chills and discomfort after about 150 mL of blood has been transfused from one unit of packed red blood cells. The best nursing action at this time is to: A. Stop the transfusion and maintain a patent line with normal saline solution and new tubing. B. Slow down the infusing blood and dilute it with the normal saline solution. C. Compare the vital signs now with what they were before the blood transfusion began. D. Discontinue the transfusion, remove the IV catheter, and restart the transfusion in another site. ### 45. The nurse determines that a client with diabetes mellitus is experiencing fat breakdown for conversion to glucose if the client has elevated levels of which substance in the urine? A. Ketones B. Protein C. Glucagon D. Lactic dehydrogenase ### 46. A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the client’s diet? A. Roast turkey B. Fried chicken C. Ice cream D. Macaroni and cheese ### 47. A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate? A. Oliguria B. Hypernatremia C. Weight loss D. Increased thirst ### 48. A nurse is caring for a client who has Cushing’s syndrome. The nurse should recognize that which of the following are manifestations of Cushing’s syndrome? **(Select all that apply.)** ### 49. A nurse is providing dietary teaching for a client who has Cushing’s disease. Which of the following recommendations should the nurse include in the teaching? A. Restrict sodium intake. B. Limit intake of potassium-rich foods. C. Increase carbohydrate intake. D. Decrease protein intake. ### 50. An insulin-dependent diabetic is admitted to the hospital for an upper respiratory tract infection and is being given a glucocorticoid steroid every 6 hours. Which statement by the nurse shows an understanding of how glucocorticoids interact with insulin? A. Glucocorticoids can increase blood sugar so the insulin dosage may need to be increased. B. Glucocorticoids can cause a drop in blood sugar so the insulin dosage may need to be decreased. C. Glucocorticoids have no effect on blood sugar, so there is no need to modify insulin dosage. D. Glucocorticoids can affect blood sugar depending on the time of insulin given so the type of insulin may need to be adjusted. ### 51. 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. ### 52. 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. ### 53. A nurse is caring for a postoperative adrenalectomy patient who has a new prescription for enoxaparin 1 mg/kg/dose subcutaneous every 12 hr. The client weighs 95 lb. How many mg should the nurse administer per dose? Round to the nearest tenth. ### 54. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases reveal pH 7.22, PaCO₂ 68 mmHg, base excess -2, PaO₂ 78 mmHg, saturation 80%, bicarbonate 26 mEq/L. Which of the following is an appropriate analysis of the ABGs? A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis ### 55. A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO₂ 48 mmHg, and HCO₃ is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis ### 56. A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? A. Check urine specific gravity. B. Measure blood glucose levels every 4 hr. C. Administer a diuretic. D. Initiate fluid restrictions. ### 57. A patient has been admitted with acute liver failure. Which assessment cue would the nurse immediately report to the provider? A. Altered mental status B. Non-pitting peripheral edema C. Jaundiced sclera and skin D. Dark tea-colored urine ### 58. The nurse is caring for a diabetic ketoacidosis (DKA) patient with orders to begin a continuous regular insulin drip 0.1 unit/kg/hr. The client weighs 198 lb. The pharmacy sends an IV bag with 100 units in 250 mL 0.9% NaCl. How many mL/hr should the nurse program the pump to deliver? Round to the nearest whole number. ### 59. A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take? A. Place the client on aspiration precautions. B. Turn the client every 4 hr. C. Check the client’s blood pressure every 2 hr. D. Initiate measures to cool the client. ### 60. Which arterial blood gas (ABG) interpretation would the nurse expect for a patient with diabetic ketoacidosis (DKA)? A. pH 7.13, PaCO₂ 30, HCO₃ 13 B. pH 7.49, PaCO₂ 29, HCO₃ 22 C. pH 7.31, PaCO₂ 49, HCO₃ 25 D. pH 7.51, PaCO₂ 32, HCO₃ 29 ### 61. A client has been diagnosed with Cushing’s syndrome. The nurse should assess the client for which expected manifestations of this disorder? A. Upper body obesity B. Dizziness C. Weight loss D. Hypoglycemia ### 62. A nurse is caring for a 54-year-old patient with a history of hypertension, diabetes, and COPD. The most recent arterial blood gas shows pH 7.3, PaCO₂ 68 mmHg, HCO₃ 30. How should the nurse interpret these results? A. Respiratory acidosis, partially compensated B. Respiratory alkalosis, partially compensated C. Metabolic acidosis, partially compensated D. Respiratory acidosis, uncompensated ### 63. A patient arrives at the emergency room complaining of being very thirsty and using the restroom more than normal. The nurse notes a respiratory rate of 24 with a “fruity” odor. Blood glucose is 452 and the arterial blood gas shows pH 7.18, PaCO₂ 38 mmHg, HCO₃ 18, PaO₂ 92 mmHg. What is the correct interpretation of these results? A. Metabolic acidosis, uncompensated B. Metabolic alkalosis, partially compensated C. Respiratory acidosis, uncompensated D. Metabolic acidosis, partially compensated ### 64. A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C? A. A client who has multiple tattoos B. A client who eats raw shellfish C. A client who works in a child care center D. A client who has recently traveled to an underdeveloped country ### 65. A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A. Practice effective hand hygiene. B. Avoid eating at fast food restaurants. C. Avoid serving raw foods. D. Wear barrier protection during vaginal intercourse. ### 66. A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? A. Chvostek’s sign B. Babinski’s sign C. Brudzinski’s sign D. Kernig’s sign ### 67. A nurse is assessing an adolescent who has an exacerbation of Graves’ disease. Which of the following findings should the nurse expect? A. Heat intolerance B. Weight gain C. Bradycardia D. Lethargy ### 68. A patient is suspected of having hepatitis. Which diagnostic procedure would the nurse anticipate for definitive diagnosis? A. Liver biopsy B. Abdominal ultrasound C. CT abdomen D. Liver function labs ### 69. A nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? A. Encourage ambulation once fully awake. B. Place the client in a supine position postoperatively. C. Offer the client ice cream postoperatively. D. Instruct the client not to lift over 4.5 kg (10 lb). For the remaining items, the report does **not display the individual answer choices**, so only the question stems are listed. ### 70. A nurse is assessing a client who has diabetic ketoacidosis (DKA) and ketones in the urine. The nurse should expect which of the following findings? **(Select all that apply.)** ### 71. A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? **(Select all that apply.)** ### 72. For each potential complication listed below, specify the potential nursing intervention(s) that would be appropriate for this client during the postoperative period. ### 73. A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? **(Select all that apply.)** ### 74. Which of the following assessment findings require immediate follow-up? **(Select all that apply.)** ### 75. What condition does the nurse suspect? Which complications and medications can the nurse anticipate? ### 76. A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider. ### 77. Identify if the nursing assessment would be expected in **myxedema coma, thyroid storm, diabetes insipidus, and/or syndrome of inappropriate antidiuretic hormone (SIADH)**. Each row must have at least 1 response but can have up to 4 responses.