ATI NCLEX REVIEW QUESTIONS RATIONALES UPDATED 2024

ATI NCLEX REVIEW QUESTIONS & RATIONALES ( UPDATED 2024 ) COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT

• A client is diagnosed with Addisonian Crisis. List the lab values that will be affected by this

disease process.: Hyperkalemia, hypercalcemia, hyponatremia, hypoglycemia, decreased cortisol levels, increased BUN/Creatinine

• A client with peripheral vascular disease had a below the knee amputation three months

ago. The client now complains of phantom limb pain. List three (3) interventions to address the pain associated with this condition.: Administer beta blockers (propranolol) which may relieve dull or burning sensations, administer antiepileptics (gabapentin, carbamazepine) to relieve sharp, stabbing sensations, alternative treatment such as massage/heat therapy or relaxation therapy.

• A nurse is caring for a client undergoing a clonidine suppresstion test to identify a

pheochromocytoma. If a client has a pheochromocytoma and is administered clonidine, what will the outcome be?: No effect, clonidine will not decrease BP

• A mass casualty event has occurred and a nurse is responsible for client triage. What

categories should the nurse use and what do these mean? (Re- view the Nursing Leadership Review Module): Emergent category (class 1) - highest priority given to pt. with life- threatening injuries, high possibility of survival once stabilized Urgent category (class 2) - second-highest priority given to pt. who have major injuries which are not yet life-threatening and can wait 45-60mins for treatment

Non-urgent category (class 3) - third-highest priority given to pt. who have minor injuries which are not life threatening and do not require immediate treatment

Expectant category (class 4) - lowest priority given to pt. who are not expected to live and will be allowed to die naturally, comfort measures may be provided, but no restorative care

• What questions should a nurse ask when obtaining a health history for a client with a

history of chest pain and dyspnea?: Frequency or intensity of the pain and if it radiates to another area, any exacerbating events, if anything makes it better/worse, how long the pain/SOB lasts, and if anything helps to reduce the dyspnea.

• A client's lab values indicate a serum sodium level of 150 mEq/L. How could this affect the

client's vital signs?: Hypernatremia - hyperreflexia, seizures, coma, confusion, increased HR and BP

• A nurse is teaching a caregiver about the use of a vacuum-assisted closure system. How

should the nurse instruct the caregiver to apply the foam strips?: Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing is placed for a negative pressure (suction) to occur once the tubing is connected to the systems therapy unit.

• What class of medication is amitriptyline and why is this medication used as an adjuvant

medication for pain?: Amitriptyline (Elavil)

Class: Tricyclic antidepressant

Use: Indicated for chronic pain syndromes (fibromyalgia, neuropathic pain, headache, lower back pain) The adjuvant medication is used to help the opiod work.

• A nurse is caring for a client with asthma who asks if montelukast sodium can be taken for

acute asthma symptoms. When should montelukast sodium be taken?: Daily at bedtime, and 2 hours before exercise for exercise induced bronchospasms.

• A client has a new prescription for salmeterol. The nurse is teaching the client about

adverse effects of the medication. What instructions should the nurse include in thus education?: Salmeterol SE - headache, heart palpitations, tachycardia, abdominal pain, diarrhea, nausea, soreness, muscle cramps, trembling, paradoxical bronchospasm, cough Clients taking salmeterol should be taught to take their pulse daily and report an increase in 20 bpm.

• A client has a new prescription for an albuterol inhaler and a beclomethasone inhaler.

What instructions should the nurse include concerning use of these inhalers?: Administer albuterol first, as albuterol enhances glucocorticoid absorption, therefore enhancing the beclomethasone absorption.

• Identify three (3) priority teaching points to include when educating a client to use a

cane.: Maintain two points of support on the ground at all times, keep the cane on the stronger side of the body, move the cane forward about 6-10 inches and then move the weaker leg toward the cane before advancing the stronger leg past the cane.

• The nurse is teaching a new parent appropriate finger foods to introduce around nine (9)

months. Identify five (5) finger foods that would be appropriate to introduce at nine (9) months.: Ripe bananas, graham crackers, noodles, pears, peaches

• List the pertinent information that should be included in a transfer report.: - Medical

diagnosis, care providers, demographic information, overview of health sta- tus, plan of care, recent progress, alterations in health status that cause immediate concern, notifications of assessments or care within the next few hours, recent vitals and medications (scheduled and PRN), allergies, diet and activity orders, specific equipment or adaptive devices, advance directives, emergency code status, family involvement in healthcare, and healthcare proxy if applicable.

• What are three (3) of the provider's responsibility for obtaining an informed consent?: The

provider must make sure that the patient understands the reason for the treatment or procedure, how the treatment or procedure will benefit the patient, and the risks involved if the patient chooses not to receive the treatment or procedure. The physician should also discuss alternatives to care if they chose to not have the procedure done.

• How should the nurse respond when the client requests information about meditation?:

Meditation uses rhythmic breathing to calm the mind and the body.

• A client is at risk for a deep vein thrombosis. What is the priority assessment for this client?

Describe the procedure to use when applying elastic stockings (TEDS).: Perform hand hygiene. Assess skin, circulation, leg edema. Measure calf/thigh circumference and the length of the leg to select correct TEDS size. Turn the stockings inside to the heel, place on the foot, pull the remainder of the stocking over the heel and on the leg, smoothing any creases or wrinkles. Remove every 8H to assess for redness, warmth, tenderness. Keep clean/dry.Document presence of TEDS.

• A client has been prescribed a mechanical soft diet. What are three (3) indications for

this therapeutic diet?: Mechanical soft diet includes clear and full liquids plus diced and ground foods, indicated by trouble chewing/swallowing, difficulty moving or loss of feeling in areas of the mouth, or surgery in the mouth.

• The nurse has been assigned to a post-abdominal surgery client who

has also been diagnosed with dementia. The family is concerned about pain control for the client because the client is confused. What should the nurse

include in their teaching to the family about the pain control plan for this client?: Vital signs are indicative of pain, therefore assessed frequently. Explain behavioral changes due to the

dementia which may indicate pain. Pre-medicate the patient prior to activities and before pain is expected. It is important for the family to understand that there are pain scales that can be used to help determine if pain medication is needed.

• A client reports difficulty falling asleep. What are nursing interventions to promote

sleep?: Promote a bedtime routine, exercise at least 2H before bedtime, personal hygiene needs to promote comfort, muscle relaxation if anxious/stressed

• A nurse is conducting an admission assessment for an older adult client with a hearing

impairment. What are some strategies the nurse can use to improve communication with this client?: Face the patient and speak slower in a normal volume, do not approach the patient from behind, make sure the patient is aware you are speaking before you initiate conversation.

• The physician prescribes meperidine 25 mg IM now for a client's pain. Available:

Meperidine 100 mg/mL How much meperidine will the nurse admin- ister?: 25 mg *

1mL/100mg = 0.25mL

• Identify three (3) manifestations of late hypoxemia.: Confusion, cyanosis, bradypnea,

bradycardia, hypotension, cardiac dysrhythmias

• What may an elderly client complain of when experiencing decreased cardiac output and

decreased contraction strength?: Anxiety, restlessness, dys- pnea, orthopnea, change in LOC, decreased activity, clammy skin, edema, weight gain, decreased urinary output.

• A nurse is administering gemfibrozil to a client with elevated cholesterol. Identify two (2)

adverse effects related to this medication.: Gemfibrozil SE - abdominal discomfort, myopathy

• A nurse is providing instructions to a client who has a prescription for methotrexate.

What should the nurse include in the client education?: Teach the patient to watch for coffee- ground emesis/black tarry stools which may indicate a GI bleed (notify HCP in the occurrence of these symptoms), watch for mouth sores, perform frequent oral hygiene, do not become pregnant while taking this medication, encourage increased fluid intake, teach the patient they will require labs to be drawn while on this med.

• A nurse is preparing to educate a client with diabetes who has a new prescription for

metformin. What should the nurse included in the client in- structions?: Contraindications: Severe infection, shock, hypoxic conditions, alcohol use disorders. Avoid during pregnancy (Pregnancy Risk Category B). Do not use iodine-containing contrast medias.Pt. Teaching: Take immediate-release tablets 2x/day with breakfast and dinner. Take sustained- release tablets once/day with dinner.

Metformin SE: GI disturbances (anorexia, nausea, diarrhea, weight loss), Vitamin B12 and Folic Acid deficiency, Lactic acidosis (hyperventilation, myalgia, sluggish- ness, somnolence)

• A nurse has provided education to a client who has a new prescription for exenatide. What

statements by the client would indicate they understand the instructions?: "I should give exenatide injection within 60 mins before the morning and evening meals, never to be