ATI COMPREHENSIVE EXAM (LATEST)

1. A nurse is caring for a client who has bipolar disorder and is experiencing acute

mania. The nurse obtained a verbal prescription for restraints. Which of the following

should the actions thenurse take?

A. Request a renewal of the prescription every 8 hr.

B. Check the client’s peripheral pulse rate every 30 min

C. Obtain a prescription for restraint within 4 hr.

D. Document the client’s condition every 15 minutes

2. A nursing planning care for a school-age child who is 4 hr postoperative

following perforated appendicitis. Which of the following actions should the nurse

include in the plan ofcare?

a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex

first)

b. Give cromolyn nebulizer solution every 6 hr (for asthma)

c. Apply a warm compress to the operative site every 4 hr

d. Administer analgesics on a scheduled basis for the first 24 hr

3. A nurse is receiving change-of-shift report for a group of clients. Which of the

followingclients should the nurse plan to assess first?

a. A client who has sinus arrhythmia and is receiving cardiac monitoring

b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%

c. A client who has epidural analgesia and weakness in the lower extremities

d. A client who has a hip fracture and a new onset of tachypnea

4. A nurse is preparing to apply a transdermal nicotine patch for a client.

Which of thefollowing actions should the nurse tak e?

a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to

promoteabsorption; avoid oily or broken skin)

b. Wear gloves to apply the patch to the client’s skin

c. Apply the patch within 1 hr of removing it from the protective pouch (apply

immediately)

d. Remove the previous patch and place it in a tissue (fold patch in half with

sticky sidespressed together)

5. A nurse has just received change-of-shift report for four clients. Which of the

followingclients should the nurse assess first?

a. A client who was just given a glass of orange juice for a low blood glucose level

b. A client who is schedule for a procedure in 1 hr (can wait)

c. A client who has 100 mL fluid remaining in his IV bag (can wait)

d. A client who received a pain medication 30 min ago for postoperative pain

6. A nurse is caring for a client who is receiving intermittent enteral tube feedings.

Which ofthe following places the client at risk for aspiration?

a. A history of gastroesophageal reflux disease

b. Receiving a high osmolarity formula

c. Sitting in a high-Fowler’s position during the feeding

d. A residual of 65 mL 1hr postprandial

7. A nurse is reviewing the laboratory results for a client who has Cushing’s

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disease. The nurse should expect the client to have an increase in which of the

following laboratory values?a. Serum glucose level- increased

b. Serum calcium level-decreased

c. Lymphocyte count- decreased immune system.

d. Serum potassium level- decreased

. 8. A nurse is caring for a client who has severe preeclampsia and is receiving

magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate

after the client displaces toxicity. Which of the following actions should the nurse

take?

a. Position the client supine

b. Prepare an IV bolus of dextrose 5% in water

c. Administer methylergonovine IM

d. Administer calcium gluconate IV

Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable

form ofcalcium gluconate available when administering magnesium sulfate by IV.

9. A charge nurse is teaching new staff members about factors that increase a client’s

risk to become violent. Which of the following risk factors should the nurse include as

the best predictorof future violence?

a. Experiencing delusions

b. Male gender

c. Previous violent behavior

d. A history of being in prison

Risk factors also include: past history of aggression, poor impulse control, and violence.

Comorbidity that leads to acts of violence (psychotic delusions, command

hallucinations, violentangry reactions with cognitive disorders).

Individual Assessment for Violence

10. A nurse is preparing to perform a sterile dressing change. Which of the

following actionsshould the nurse take when setting up the sterile field?

a. Place the cap from the solution sterile side up on clean surface

b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from

the body'sfirst

c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field →

2.5 cm(1-inch) border around any sterile drape or wrap that is considered

contaminated.

d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;

shouldbe ABOVE waist level

11. A nurse is providing teaching to an older adult client about methods to promote

nighttimesleep. Which of the following instructions should the nurse include?

a. Eat a light snack before bedtime

b. Stay in bed at least 1 hr if unable to fall asleep

c. Take a 1 hr nap during the day

d. Perform exercises prior to bedtime

12. A home health nurse is preparing for an initial visit with an older adult client

who livesalone. Which of the following actions should the nurse take first?

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a. Educate the client about current medical diagnosis

b. Refer the client to a meal delivery program

c. Identify environmental hazards in the home

d. Arrange for client transportation to follow-up

appointmentsRationale Priority: Assess first.

13. A nurse is assessing the remote memory of an older adult client who has mild

dementia.Which of the following questions should the nurse ask the client?

a. “Can you tell me who visited you today?”

b. “What high school did you graduate from

c. “Can you list your current medications?”

d. “What did you have for breakfast yesterday?”

14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.

Which ofthe following goals should the nurse include in the teaching

a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >

b. Blood glucose level greater than 200 mg/dL at bedtime

c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =

HYPOGLYCEMICd. HbA1c level less than 7%

15. A nurse is caring for a client who is receiving phenytoin for management of

grand mal seizures and has a new prescription for isoniazid and rifampin. Which of

the following shouldthe nurse conclude if the client develops ataxia and

incoordination?

a. The client is experiencing an adverse reaction to rifampin

b. The client’s seizure disorder is no longer under

controlc. The client is showing evidence of

phenytoin toxicity

d. The client is having adverse effects due to combination antimicrobial therapy

16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.

Which of thefollowing manifestations requires immediate action by the nurse?

a. Increase in frequency of swallowing→ may indicate bleeding

b. Moderate sanguineous drainage on the drip pad

c. Bruising to the face→ side effect

d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)

Rationale “Requires immediate action” choose the worst possibility that could lead

to. ABC

17. A nurse is planning care for a preschool-age child who is in the acute phase

Kawasakidisease. Which of the following interventions should the nurse include

in the plan of care?

a. Give scheduled doses of acetaminophen

every 6 hrb. Monitor the child’s cardiac status

c. Administer antibiotics via intermittent IV bolus for 24 hr

d. Provide stimulation with children of the same age in the playroom

18. A nurse is planning an educational program for high school students about

cigarette smoking. Which of the following potential consequences of smoking is most

likely to discourageadolescents from using tobacco?

a. Use of tobacco might lead to alcohol and drug abuse

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