ATI practice NCLEX
an older adult client reports recurring calf pain after walking one block that
disappears with rest. the client has weak pedal pulses and the skin on the left lower
extremity is shiny and cool to touch. Which nursing intervention is appropriate at this
time?
1. position left leg dependently
2. elevate left leg above the heart
✅✅
3. immobilize left leg to prevent further injury
4. assess dorsiflexion and extension of left foot - -1. position left leg
dependently
a client receives a transfusion of packed RBC's and tells the nurse "my IV site is
painful and looks swollen". Which action should the nurse take?
1. continue to monitor site for signs of infection or infiltration.
2. double check blood type of unit of blood with another RN.
3. start a new IV at another site and resume transfusion.
✅✅
4. discontinue the transfusion and send the remaining blood and tubing to lab. -
-3. start a new IV at another site and resume transfusion.
a client who has recently undergone surgery for a new trach is now at home. the RN
recognizes a need for immediate intervention when the caregiver does which of the
following?
1. suctions intermittently for 15 sec
2. places air humidifier at bedside
✅✅
3. cuts 4x4 gauze to put around trach
4. removes ties before cleaning the trach - -4. removes ties before cleaning the
trach
A nurse enters the room of a client who is lying on the floor. What should be the
initial action of the RN?
1. examine pt for injuries
2. obtain pulse and blood pressure
✅✅
3. assess VS and LOC
4. determine intensity of pain with ROM - -3. assess VS and LOC
Four days after a ventral hernia repair, a client is obese and has a hx of COPD,
vomits and reports severe abdominal pain. O2 is 90%. Which action should the RN
implement first?
1. administer ondansetron hcl IV
2. encourage pursed lip breathing
✅✅
3. assess surgical incision
4. apply low dose O2 NC - -3. assess surgical incision
, A nurse arrives at a work site explosion. Which client should be triaged first?
1. fixed pupils and agonal respirations
2. burns to the face and respiratory stridor
✅✅
3. type 2 diabetic who is disoriented
4. a closed fracture reporting 3/10 pain - -2. burns to the face and respiratory
stridor
Of the following what is an early sign of hemorrhage?
1. cold clammy skin
2. HR 120
✅✅
3. weak, thready pulses
4. BP 80/66 - -2. HR 120
A pt has a C3 spinal injury, which of the following VS take priority?
1. HR 52
2. RR 10
✅✅
3. temp 97
4. BP 88/60 - -2. RR 10
A pt with an RA diagnosis is to take methotrexate for 3 months. What are the
adverse effects? SATA
1. WBC 1200
2. weight gain of 10 lbs
3. temp 99
✅✅
4. urine specific gravity 1.003
5. platelets 5,000 - -1. WBC 1200
5. platelets 5,000
A client who lives a long-term care facility is at high risk for falls. Which actions
should the RN implement?
1. place walked at foot of bed
2. keep all 4 side rails up throughout night
3. maintain clear path from bed to bathroom
4. put items on bedside table within reach
✅✅
5. check client Q4 to ensure safety
6. ask the client to use the call bell before getting up - -3. maintain clear path
from bed to bathroom
4. put items on bedside table within reach
6. ask the client to use the call bell before getting up
While visiting with a family member, a client repeatedly attempts to tie the oxygen
tubing in knots. The family member asks the RN "why dont you just tie his arms
down?" Which response by the RN is correct?
1. a consent form to use restraints has not been signed at this time
an older adult client reports recurring calf pain after walking one block that
disappears with rest. the client has weak pedal pulses and the skin on the left lower
extremity is shiny and cool to touch. Which nursing intervention is appropriate at this
time?
1. position left leg dependently
2. elevate left leg above the heart
✅✅
3. immobilize left leg to prevent further injury
4. assess dorsiflexion and extension of left foot - -1. position left leg
dependently
a client receives a transfusion of packed RBC's and tells the nurse "my IV site is
painful and looks swollen". Which action should the nurse take?
1. continue to monitor site for signs of infection or infiltration.
2. double check blood type of unit of blood with another RN.
3. start a new IV at another site and resume transfusion.
✅✅
4. discontinue the transfusion and send the remaining blood and tubing to lab. -
-3. start a new IV at another site and resume transfusion.
a client who has recently undergone surgery for a new trach is now at home. the RN
recognizes a need for immediate intervention when the caregiver does which of the
following?
1. suctions intermittently for 15 sec
2. places air humidifier at bedside
✅✅
3. cuts 4x4 gauze to put around trach
4. removes ties before cleaning the trach - -4. removes ties before cleaning the
trach
A nurse enters the room of a client who is lying on the floor. What should be the
initial action of the RN?
1. examine pt for injuries
2. obtain pulse and blood pressure
✅✅
3. assess VS and LOC
4. determine intensity of pain with ROM - -3. assess VS and LOC
Four days after a ventral hernia repair, a client is obese and has a hx of COPD,
vomits and reports severe abdominal pain. O2 is 90%. Which action should the RN
implement first?
1. administer ondansetron hcl IV
2. encourage pursed lip breathing
✅✅
3. assess surgical incision
4. apply low dose O2 NC - -3. assess surgical incision
, A nurse arrives at a work site explosion. Which client should be triaged first?
1. fixed pupils and agonal respirations
2. burns to the face and respiratory stridor
✅✅
3. type 2 diabetic who is disoriented
4. a closed fracture reporting 3/10 pain - -2. burns to the face and respiratory
stridor
Of the following what is an early sign of hemorrhage?
1. cold clammy skin
2. HR 120
✅✅
3. weak, thready pulses
4. BP 80/66 - -2. HR 120
A pt has a C3 spinal injury, which of the following VS take priority?
1. HR 52
2. RR 10
✅✅
3. temp 97
4. BP 88/60 - -2. RR 10
A pt with an RA diagnosis is to take methotrexate for 3 months. What are the
adverse effects? SATA
1. WBC 1200
2. weight gain of 10 lbs
3. temp 99
✅✅
4. urine specific gravity 1.003
5. platelets 5,000 - -1. WBC 1200
5. platelets 5,000
A client who lives a long-term care facility is at high risk for falls. Which actions
should the RN implement?
1. place walked at foot of bed
2. keep all 4 side rails up throughout night
3. maintain clear path from bed to bathroom
4. put items on bedside table within reach
✅✅
5. check client Q4 to ensure safety
6. ask the client to use the call bell before getting up - -3. maintain clear path
from bed to bathroom
4. put items on bedside table within reach
6. ask the client to use the call bell before getting up
While visiting with a family member, a client repeatedly attempts to tie the oxygen
tubing in knots. The family member asks the RN "why dont you just tie his arms
down?" Which response by the RN is correct?
1. a consent form to use restraints has not been signed at this time
