ATI Cbc Level 4

Free preview · Original latest version

Sample questions from ATI Cbc Level 4

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

1. 1.At change of shift on a medical-surgical unit, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 68-year-old client with heart failure who gained 1 kg in 24 hours and has new crackles at the lung bases
   • B.A 52-year-old client with diabetes whose premeal glucose is 248 mg/dL and who is requesting lunch
   • C.A 45-year-old client 8 hours after thyroidectomy who reports tingling around the mouth and has a respiratory rate of 22/min
   • D.A 73-year-old client with pneumonia whose temperature is 38.1 C and who is due for an antipyretic

   Rationale: Perioral tingling after thyroidectomy can indicate hypocalcemia, which may progress to laryngospasm and airway compromise, so this client requires immediate assessment. The heart failure client has a concerning fluid trend but no reported acute respiratory distress. The fever and elevated glucose require timely care, but neither finding takes priority over a possible evolving airway emergency. Prioritize threats to airway and rapid deterioration over stable, expected, or treatable abnormalities.

2. 2.During a home health visit, a 4-year-old client with cystic fibrosis has a temperature of 37.2 C, respiratory rate of 24/min, and oxygen saturation of 97% on room air. The parent asks the nurse to help with the child's scheduled airway-clearance treatment while the nurse reviews the care plan. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Teach the parent how to recognize signs of respiratory distress
   • B.Evaluate whether the prescribed airway-clearance treatment improved the child's cough
   • C.Assess the child's breath sounds before the airway-clearance treatment
   • D.Record the child's oxygen saturation and report it to the nurse

   Rationale: A UAP may obtain and report routine, objective data such as oxygen saturation when the client is stable and the task is within agency policy. Assessing breath sounds and evaluating treatment response require nursing judgment. Teaching the parent also remains the nurse's responsibility. Delegation transfers a task, not accountability for interpreting findings or responding to changes.

3. 3.Refer to the client's chart. Which actions should the charge nurse take now to manage this client's worsening condition? Select all that apply.

   • A.Position the client upright and apply oxygen according to protocol while preparing for escalation
   • B.Ask the UAP to obtain another set of vital signs while the nurse remains with the client
   • C.Notify the rapid response team and the provider about the acute change
   • D.Wait for the next scheduled laboratory result before notifying the provider
   • E.Delegate assessment of the client's mental status to the UAP

   Rationale: The client's increasing respiratory rate, falling oxygen saturation, new confusion, and rising heart rate indicate acute deterioration, so escalation and immediate supportive measures are appropriate. A UAP can obtain and report repeat vital signs while the nurse stays with the client, but assessment of mental status requires nursing judgment. Waiting for scheduled laboratory results delays action despite clear clinical worsening. The nurse should continue reassessment and follow facility emergency protocols.

4. 4.In a pediatric clinic, the parent of a 9-year-old client scheduled for a lumbar puncture says, "I signed the form, but I do not understand why this test is needed." The client is calm, has a temperature of 37.0 C, and has no neurologic changes. What should the nurse do?

   • A.Continue preparation because the parent has already signed the consent form
   • B.Pause preparation and notify the provider that the parent needs further explanation before consent
   • C.Ask the child to decide whether the procedure should proceed
   • D.Explain the procedure's risks and benefits and ask the parent to sign again

   Answer and rationale are in the full material.

5. 5.A provider prescribes an IV heparin infusion for a 58-year-old client with a new pulmonary embolism. The client weighs 70 kg, and the prescription reads 1,260 units/hr. The available infusion contains 25,000 units in 250 mL. The client is hemodynamically stable, with BP 126/78 mm Hg and oxygen saturation 95% on 2 L/min. What should the nurse do before starting the infusion?

   • A.Clarify the prescription because the rate exceeds the usual weight-based starting rate of 18 units/kg/hr
   • B.Reduce the infusion to 1,000 units/hr and notify the provider after administration
   • C.Begin the infusion and check the activated partial thromboplastin time in 6 hours
   • D.Ask another nurse to independently verify the calculation and then begin the infusion

   Answer and rationale are in the full material.