ATI Ns 250

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Sample questions from ATI Ns 250

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.During a home visit, a public health nurse evaluates a 3-day-old newborn whose parent reports that the infant is difficult to awaken for feeds. The newborn's temperature is 36.2 C, heart rate is 148/min, and respiratory rate is 42/min. Which action should the nurse take first?

   • A.Schedule a weight check at the clinic for the following day.
   • B.Ask the parent to keep a record of wet diapers for 24 hours.
   • C.Arrange immediate evaluation at an emergency department.
   • D.Teach the parent to offer feeds every 3 hours.

   Rationale: A newborn who is difficult to awaken and has a temperature of 36.2 C requires prompt evaluation for potentially serious illness. Feeding instruction, a next-day appointment, and diaper tracking do not address the immediate risk of deterioration. The priority is to facilitate urgent assessment rather than delay care for routine monitoring.

2. 2.At change of shift on a medical unit, a charge nurse receives reports about four clients. Which client should the charge nurse assign to an experienced registered nurse rather than a newly licensed registered nurse?

   • A.A 72-year-old client who needs assistance with a routine dressing change
   • B.A 16-year-old client with a new tracheostomy who has increasing secretions and a change in oxygen saturation from 97% to 91%
   • C.A 67-year-old client with stable heart failure who needs routine medication teaching before discharge
   • D.A 46-year-old client awaiting transport for a scheduled radiology study

   Rationale: The adolescent with a new tracheostomy and falling oxygen saturation has a changing airway condition that requires skilled assessment and rapid clinical judgment. Routine teaching, transport coordination, and a scheduled dressing change are more predictable tasks that can be assigned to a less experienced registered nurse, depending on competency and workload. Assigning clients according to acuity and the need for ongoing assessment promotes safe care.

3. 3.In a long-term care facility, a 90-year-old resident with mild dementia is scheduled for a procedure requiring informed consent. The resident says, "I don't understand what they are going to do." Which action should the nurse take?

   • A.Ask the resident's adult child to sign the consent form.
   • B.Witness the resident's signature because the procedure is scheduled.
   • C.Explain the procedure and ask the resident to sign.
   • D.Notify the provider that the resident needs further explanation before consent is obtained.

   Rationale: The resident's statement indicates that the procedure has not been adequately understood, so the provider performing the procedure must clarify the information before consent is obtained. Mild dementia alone does not establish incapacity or automatically authorize a family member to sign. The nurse may witness a signature but should not obtain consent by substituting for the provider's explanation.

4. 4.Refer to the client's chart. A nurse is coordinating care for a 23-year-old pregnant client admitted to an antepartum unit. Which actions should the nurse take now? Select all that apply.

   • A.Encourage the client to ambulate in the hallway to lower the blood pressure.
   • B.Administer the prescribed magnesium sulfate loading dose after verifying the order and required safety checks.
   • C.Delay notifying the provider until the next scheduled vital-sign check.
   • D.Notify the provider promptly about the persistent severe-range blood pressure.
   • E.Reassess the client's blood pressure and neurologic symptoms while awaiting further direction.

   Answer and rationale are in the full material.

5. 5.A 4-year-old is seen at a community clinic after a parent reports that the child may have swallowed an unknown number of the parent's tablets. The child is awake and has no symptoms; vital signs are within age-appropriate limits. Which action should the nurse take first?

   • A.Call the poison control center and provide the medication and exposure details.
   • B.Ask the parent to observe the child at home for sleepiness.
   • C.Induce vomiting to remove any remaining tablets.
   • D.Schedule a clinic appointment for later in the day.

   Answer and rationale are in the full material.