ATI NCLEX QUESTIONS AND ANSWERS WITH RATIONALES
1. Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional
antipsychotic medications. The client should be monitored for changes in vital signs,
tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol.
There is a risk for cardiac arrest due to torsades de pointes.
2. Body weight is the most reliable indicator of fluid loss for infants and young children.
3. Measles, mumps rubella (MMR) is correct. A 1-year-old child should receive the first of two
doses of the MMR vaccine.
Diphtheria, tetanus and acellular pertussis (DTaP) is incorrect. By 1 year of age, the child
should have already received three doses of DTaP: at 2 months, 4 months, and 6 months.
The child should receive a fourth dose at 15 months of age.
Varicella (VAR) is correct. A 1-year-old child should receive the first of two doses of the VAR
vaccine.
Rotavirus (RV) is incorrect. A 1-year-old child should have received the RV vaccine in a two
or three dose series starting at 2 months of age.
Human papillomavirus (HPV4) is incorrect. A child should receive a three dose series of the
HPV4 vaccine at 11 or 12 years of age.
4. The client has paralysis from the level of the defect down. In the majority of cases,
this condition affects bladder and bowel continence. Catheterization should be
performed every 4 hr. Infrequent emptying of the bladder can result in stasis and
urinary tract infections.
5. Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the
risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing
thrombus formation in an artery, a vein, or the heart.
6. Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of
antipsychotic (haloperidol) medications that requires emergency medical intervention.
Manifestations of NMS are sudden and include changes in level of consciousness,
seizures, and stupor.
7. A negative rubella titer indicates that the client is susceptible to the rubella virus and
needs vaccination following delivery. Immunization during pregnancy is contraindicated
because of possible injury to the developing fetus. Following rubella immunization, the
client should be cautioned not to conceive for 1 month.
8. Any adult who has a respiratory rate of over 30/min requires immediate attention.
Additionally, this patient is unconscious, which constitutes altered mental status. This
client is the client he nurse should care for first.
9. Plan the client's schedule to allow time for rituals.
10. OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels
MY
driven to perform. This behavior can be a physical action or a mental act that is aimed at
neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow
adequate time for the client to perform rituals to help the client handle anxiety.
11. Propranolol, a beta-blocker, is contraindicated in clients who have asthma because
it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which
prevents smooth muscle relaxation.
,12. Noxious gas: Following the principle of mitigation, the nurse should facilitate
evacuation out of the building to prevent exposure to the harmful gas and set up the
triage site at a nearby location.
13. Urinary frequency is due to increased bladder sensitivity during the first trimester and
recurs near the end of the pregnancy as the enlarging uterus places pressure on the
bladder.
14. Assessment of progressive changes in the effacement and dilation of the cervix is the
most accurate indication of true labor.
15. Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is
that health care workers refrain from intentionally inflicting harm to clients.
16. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk
for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the
client engages in strenuous exercise during hot weather, she should take care to replace
any water and sodium that have been lost through profuse sweating. This also applies to
other factors that can cause the client to become dehydrated, such as having diarrhea
or taking diuretics.
17. Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in
which they become weakened and collapse. Dyspnea is seen in clients with
emphysema as the lungs try to increase the amount of oxygen available to the
tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm
becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib
cage become rigid; and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels.
The tips of the fingers enlarge, and the nails become extremely curved from front to
back.
18. Rice, potatoes, and oranges
19. This group of foods contains the highest level of carbohydrates.
MY ANS
20. What part of the exam makes you most nervous?"
21. This therapeutic response recognizes the client's feelings. It also uses the therapeutic
MY ANSW ER
technique of clarification to encourage the client to tell the nurse more about her
concerns.
22. Red meat and organ meat
23. This client has a deficiency in iron and needs instruction about foods that are rich
MY ANSW ER
sources of iron. A diet rich in red and organ meat provides iron, which is what the client
24.
25.
needs to improve anemia.
26.
23. a nurse is planning to teach a client about a low-potassium diet. Which of the
following foods should the nurse instruct the client to avoid? Yogurt, Orange Juice
24. Hypotension is correct. Lack of sympathetic input can cause a decrease in blood
pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to
adequately perfuse the spinal cord.
Polyuria is incorrect. The nurse should check the client for bladder distention and inability
to urinate due to ineffective function of the bladder muscles.
,Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which
could cause the client to develop a paralytic ileus.
, Weakened gag reflex is correct. The nurse should monitor the client for difficulty
swallowing, or coughing and drooling noted with oral intake.
25. A nurse is caring for a client who is admitted with acute psychosis and is being
treated with haloperidol (Haldol). The nurse should suspect that the client may be
experiencing tardive dyskinesia as an adverse reaction when the client exhibits which of
the following? (Select all that apply.)
a) Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as tongue thrusting and lip smacking.
.
Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as facial grimacing and eye blinking.
Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and
involuntary movements of the head, neck, trunk, and extremities can occur in tardive
dyskinesia.
26. nurse is providing education about introducing new foods to the parents of a 4-
month-old infant. The nurse should recommend that the parents introduce which of the
following foods first?
Iron-fortified cereal should be the first solid food introduced to the
infant.
29. Pull the curtains around the client's bed: Pulling the curtains around the client's bed
assures privacy for the client should someone open the door or enter the room.
30. Ask the client to describe the situation. WER
a. During the acute phase following assault, the nurse should encourage the
client to provide information which may be helpful with treatment and to
reduce the client’s anxiety.
31.
32. Anurseaccidentallyadministersth
ewrongmedicationtoaclient,which
resultsinasevereallergicreactionan
dprolongstheclient’shospitalization
.The
clientcouldrightfullysuethenursefo
rwhichofthefollowing?Malpractice
The client could sue the nurse for malpractice, which is the failure to meet the standard of
conduct
another professional would exercise in similar circumstances and that failure causes
harm. This nurse has made an error that harmed the client.
33. A client on a mental health unit refuses treatment and asks to
be discharged from the hospital against medical advice. The nurse
notifies the client's provider, who tells the nurse to restrain the client,
if necessary, to prevent him from leaving the hospital. Restraining this
client would be considered which type of civil action by the nurse?
False imprisonment
1. Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional
antipsychotic medications. The client should be monitored for changes in vital signs,
tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol.
There is a risk for cardiac arrest due to torsades de pointes.
2. Body weight is the most reliable indicator of fluid loss for infants and young children.
3. Measles, mumps rubella (MMR) is correct. A 1-year-old child should receive the first of two
doses of the MMR vaccine.
Diphtheria, tetanus and acellular pertussis (DTaP) is incorrect. By 1 year of age, the child
should have already received three doses of DTaP: at 2 months, 4 months, and 6 months.
The child should receive a fourth dose at 15 months of age.
Varicella (VAR) is correct. A 1-year-old child should receive the first of two doses of the VAR
vaccine.
Rotavirus (RV) is incorrect. A 1-year-old child should have received the RV vaccine in a two
or three dose series starting at 2 months of age.
Human papillomavirus (HPV4) is incorrect. A child should receive a three dose series of the
HPV4 vaccine at 11 or 12 years of age.
4. The client has paralysis from the level of the defect down. In the majority of cases,
this condition affects bladder and bowel continence. Catheterization should be
performed every 4 hr. Infrequent emptying of the bladder can result in stasis and
urinary tract infections.
5. Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the
risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing
thrombus formation in an artery, a vein, or the heart.
6. Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of
antipsychotic (haloperidol) medications that requires emergency medical intervention.
Manifestations of NMS are sudden and include changes in level of consciousness,
seizures, and stupor.
7. A negative rubella titer indicates that the client is susceptible to the rubella virus and
needs vaccination following delivery. Immunization during pregnancy is contraindicated
because of possible injury to the developing fetus. Following rubella immunization, the
client should be cautioned not to conceive for 1 month.
8. Any adult who has a respiratory rate of over 30/min requires immediate attention.
Additionally, this patient is unconscious, which constitutes altered mental status. This
client is the client he nurse should care for first.
9. Plan the client's schedule to allow time for rituals.
10. OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels
MY
driven to perform. This behavior can be a physical action or a mental act that is aimed at
neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow
adequate time for the client to perform rituals to help the client handle anxiety.
11. Propranolol, a beta-blocker, is contraindicated in clients who have asthma because
it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which
prevents smooth muscle relaxation.
,12. Noxious gas: Following the principle of mitigation, the nurse should facilitate
evacuation out of the building to prevent exposure to the harmful gas and set up the
triage site at a nearby location.
13. Urinary frequency is due to increased bladder sensitivity during the first trimester and
recurs near the end of the pregnancy as the enlarging uterus places pressure on the
bladder.
14. Assessment of progressive changes in the effacement and dilation of the cervix is the
most accurate indication of true labor.
15. Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is
that health care workers refrain from intentionally inflicting harm to clients.
16. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk
for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the
client engages in strenuous exercise during hot weather, she should take care to replace
any water and sodium that have been lost through profuse sweating. This also applies to
other factors that can cause the client to become dehydrated, such as having diarrhea
or taking diuretics.
17. Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in
which they become weakened and collapse. Dyspnea is seen in clients with
emphysema as the lungs try to increase the amount of oxygen available to the
tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm
becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib
cage become rigid; and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels.
The tips of the fingers enlarge, and the nails become extremely curved from front to
back.
18. Rice, potatoes, and oranges
19. This group of foods contains the highest level of carbohydrates.
MY ANS
20. What part of the exam makes you most nervous?"
21. This therapeutic response recognizes the client's feelings. It also uses the therapeutic
MY ANSW ER
technique of clarification to encourage the client to tell the nurse more about her
concerns.
22. Red meat and organ meat
23. This client has a deficiency in iron and needs instruction about foods that are rich
MY ANSW ER
sources of iron. A diet rich in red and organ meat provides iron, which is what the client
24.
25.
needs to improve anemia.
26.
23. a nurse is planning to teach a client about a low-potassium diet. Which of the
following foods should the nurse instruct the client to avoid? Yogurt, Orange Juice
24. Hypotension is correct. Lack of sympathetic input can cause a decrease in blood
pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to
adequately perfuse the spinal cord.
Polyuria is incorrect. The nurse should check the client for bladder distention and inability
to urinate due to ineffective function of the bladder muscles.
,Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which
could cause the client to develop a paralytic ileus.
, Weakened gag reflex is correct. The nurse should monitor the client for difficulty
swallowing, or coughing and drooling noted with oral intake.
25. A nurse is caring for a client who is admitted with acute psychosis and is being
treated with haloperidol (Haldol). The nurse should suspect that the client may be
experiencing tardive dyskinesia as an adverse reaction when the client exhibits which of
the following? (Select all that apply.)
a) Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as tongue thrusting and lip smacking.
.
Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as facial grimacing and eye blinking.
Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and
involuntary movements of the head, neck, trunk, and extremities can occur in tardive
dyskinesia.
26. nurse is providing education about introducing new foods to the parents of a 4-
month-old infant. The nurse should recommend that the parents introduce which of the
following foods first?
Iron-fortified cereal should be the first solid food introduced to the
infant.
29. Pull the curtains around the client's bed: Pulling the curtains around the client's bed
assures privacy for the client should someone open the door or enter the room.
30. Ask the client to describe the situation. WER
a. During the acute phase following assault, the nurse should encourage the
client to provide information which may be helpful with treatment and to
reduce the client’s anxiety.
31.
32. Anurseaccidentallyadministersth
ewrongmedicationtoaclient,which
resultsinasevereallergicreactionan
dprolongstheclient’shospitalization
.The
clientcouldrightfullysuethenursefo
rwhichofthefollowing?Malpractice
The client could sue the nurse for malpractice, which is the failure to meet the standard of
conduct
another professional would exercise in similar circumstances and that failure causes
harm. This nurse has made an error that harmed the client.
33. A client on a mental health unit refuses treatment and asks to
be discharged from the hospital against medical advice. The nurse
notifies the client's provider, who tells the nurse to restrain the client,
if necessary, to prevent him from leaving the hospital. Restraining this
client would be considered which type of civil action by the nurse?
False imprisonment
