ATI PN COMPREHENSIVE EXIT EXAM
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GRADED A+ LATEST
1. A nurse is caring for a client who is post-operative following a total hip
replacement. The client reports sudden shortness of breath and chest pain. Which
of the following actions should the nurse take first?
A. Administer oxygen via nasal cannula
B. Notify the provider immediately
C. Place the client in high Fowler’s position
D. Obtain vital signs
Answer: C. Place the client in high Fowler’s position
Rationale: The first action in an acute scenario is to promote airway and
breathing. High Fowler’s improves ventilation and oxygenation. Administering
oxygen and notifying the provider are important, but first the nurse ensures the
client can breathe effectively.
2. A nurse is reviewing a new prescription for digoxin for a client with heart
failure. Which of the following findings should prompt the nurse to hold the
medication and notify the provider?
A. Apical pulse 88/min
B. Serum potassium 3.0 mEq/L
C. Blood pressure 120/78 mmHg
D. Respiratory rate 18/min
Answer: B. Serum potassium 3.0 mEq/L
Rationale: Hypokalemia increases the risk of digoxin toxicity. The nurse should
hold the medication and notify the provider. The apical pulse, BP, and RR are
within normal limits.
,3. A nurse is teaching a client about foods that are high in potassium. Which of the
following foods should the nurse include?
A. Bananas
B. Oranges
C. Spinach
D. White rice
E. Apples
Answer: A, B, C
Rationale: Foods high in potassium include bananas, oranges, and spinach.
White rice and apples are low in potassium.
4. A nurse is caring for a client who has a nasogastric tube attached to suction. The
client’s stomach distends, and the nurse notes vomiting. Which of the following is
the priority action?
A. Irrigate the NG tube with normal saline
B. Assess the NG tube for obstruction
C. Place the client in a supine position
D. Document the findings
Answer: B. Assess the NG tube for obstruction
Rationale: Airway, breathing, and circulation remain priority. Vomiting and
abdominal distention may indicate NG tube obstruction, which must be relieved
promptly to prevent aspiration and further complications.
5. A nurse is caring for four clients. Which client should the nurse assess first?
1. A client 1 day post-op cholecystectomy who has mild incisional pain
2. A client with pneumonia who has oxygen saturation 85%
3. A client with hypertension who reports mild headache
4. A client scheduled for discharge with stable vital signs
Answer: 2. A client with pneumonia who has oxygen saturation 85%
,Rationale: The client with hypoxemia is experiencing a potentially life-
threatening problem and requires immediate intervention. Post-op pain, mild
headache, and stable discharge are lower priority.
6. A nurse is administering morphine sulfate 4 mg IV to a client for post-op pain.
Which assessment finding requires the nurse to withhold the medication?
A. Blood pressure 130/80 mmHg
B. Respiratory rate 8/min
C. Heart rate 82/min
D. Client reports pain as 8/10
Answer: B. Respiratory rate 8/min
Rationale: Morphine is a respiratory depressant. RR < 10/min is a
contraindication for administration. The other findings do not require withholding.
7. A nurse is reviewing lab results for four clients. Which findings require
immediate intervention?
A. WBC 18,000/mm³
B. Sodium 138 mEq/L
C. Hemoglobin 6.8 g/dL
D. Platelets 25,000/mm³
E. Blood glucose 110 mg/dL
Answer: A, C, D
Rationale: WBC 18,000 indicates infection, hemoglobin 6.8 indicates severe
anemia, and platelets 25,000 indicate risk for bleeding. Sodium and blood
glucose are within normal limits.
, 8. A nurse is planning care for a client who has heart failure. Which intervention
should the nurse include?
A. Encourage bed rest all day
B. Monitor daily weight
C. Encourage high-sodium foods
D. Limit fluid intake to 1 L/day
Answer: B. Monitor daily weight
Rationale: Daily weight helps detect fluid retention early in heart failure. Bed
rest is not required all day, high-sodium foods worsen fluid retention, and fluid
restriction depends on the provider’s orders.
9. A licensed practical nurse (LPN) asks the nurse to administer a blood
transfusion to a stable client. Which action is appropriate for the nurse to take?
A. Delegate the transfusion to the LPN
B. Refuse to delegate the task
C. Allow the LPN to monitor vital signs only
D. Have the LPN prepare the blood and nurse administers
Answer: B. Refuse to delegate the task
Rationale: Blood transfusions are beyond the LPN scope in most states. The RN
is responsible for the administration. Delegating monitoring after RN initiates may
be appropriate, but initial administration cannot be delegated.
10. A nurse is providing teaching to a client who is prescribed warfarin. Which
statement indicates understanding?
A. “I will take aspirin for any pain I have.”
B. “I will eat a consistent amount of leafy green vegetables each day.”
C. “I do not need to have lab tests while on this medication.”
D. “I can stop the medication once I feel better.”
Answer: B. “I will eat a consistent amount of leafy green vegetables each day.”
Rationale: Vitamin K affects warfarin effectiveness. Consistency in intake helps
maintain therapeutic INR. Aspirin increases bleeding risk, labs are required, and
warfarin should not be stopped without provider guidance.
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES GRADED A+ LATEST
1. A nurse is caring for a client who is post-operative following a total hip
replacement. The client reports sudden shortness of breath and chest pain. Which
of the following actions should the nurse take first?
A. Administer oxygen via nasal cannula
B. Notify the provider immediately
C. Place the client in high Fowler’s position
D. Obtain vital signs
Answer: C. Place the client in high Fowler’s position
Rationale: The first action in an acute scenario is to promote airway and
breathing. High Fowler’s improves ventilation and oxygenation. Administering
oxygen and notifying the provider are important, but first the nurse ensures the
client can breathe effectively.
2. A nurse is reviewing a new prescription for digoxin for a client with heart
failure. Which of the following findings should prompt the nurse to hold the
medication and notify the provider?
A. Apical pulse 88/min
B. Serum potassium 3.0 mEq/L
C. Blood pressure 120/78 mmHg
D. Respiratory rate 18/min
Answer: B. Serum potassium 3.0 mEq/L
Rationale: Hypokalemia increases the risk of digoxin toxicity. The nurse should
hold the medication and notify the provider. The apical pulse, BP, and RR are
within normal limits.
,3. A nurse is teaching a client about foods that are high in potassium. Which of the
following foods should the nurse include?
A. Bananas
B. Oranges
C. Spinach
D. White rice
E. Apples
Answer: A, B, C
Rationale: Foods high in potassium include bananas, oranges, and spinach.
White rice and apples are low in potassium.
4. A nurse is caring for a client who has a nasogastric tube attached to suction. The
client’s stomach distends, and the nurse notes vomiting. Which of the following is
the priority action?
A. Irrigate the NG tube with normal saline
B. Assess the NG tube for obstruction
C. Place the client in a supine position
D. Document the findings
Answer: B. Assess the NG tube for obstruction
Rationale: Airway, breathing, and circulation remain priority. Vomiting and
abdominal distention may indicate NG tube obstruction, which must be relieved
promptly to prevent aspiration and further complications.
5. A nurse is caring for four clients. Which client should the nurse assess first?
1. A client 1 day post-op cholecystectomy who has mild incisional pain
2. A client with pneumonia who has oxygen saturation 85%
3. A client with hypertension who reports mild headache
4. A client scheduled for discharge with stable vital signs
Answer: 2. A client with pneumonia who has oxygen saturation 85%
,Rationale: The client with hypoxemia is experiencing a potentially life-
threatening problem and requires immediate intervention. Post-op pain, mild
headache, and stable discharge are lower priority.
6. A nurse is administering morphine sulfate 4 mg IV to a client for post-op pain.
Which assessment finding requires the nurse to withhold the medication?
A. Blood pressure 130/80 mmHg
B. Respiratory rate 8/min
C. Heart rate 82/min
D. Client reports pain as 8/10
Answer: B. Respiratory rate 8/min
Rationale: Morphine is a respiratory depressant. RR < 10/min is a
contraindication for administration. The other findings do not require withholding.
7. A nurse is reviewing lab results for four clients. Which findings require
immediate intervention?
A. WBC 18,000/mm³
B. Sodium 138 mEq/L
C. Hemoglobin 6.8 g/dL
D. Platelets 25,000/mm³
E. Blood glucose 110 mg/dL
Answer: A, C, D
Rationale: WBC 18,000 indicates infection, hemoglobin 6.8 indicates severe
anemia, and platelets 25,000 indicate risk for bleeding. Sodium and blood
glucose are within normal limits.
, 8. A nurse is planning care for a client who has heart failure. Which intervention
should the nurse include?
A. Encourage bed rest all day
B. Monitor daily weight
C. Encourage high-sodium foods
D. Limit fluid intake to 1 L/day
Answer: B. Monitor daily weight
Rationale: Daily weight helps detect fluid retention early in heart failure. Bed
rest is not required all day, high-sodium foods worsen fluid retention, and fluid
restriction depends on the provider’s orders.
9. A licensed practical nurse (LPN) asks the nurse to administer a blood
transfusion to a stable client. Which action is appropriate for the nurse to take?
A. Delegate the transfusion to the LPN
B. Refuse to delegate the task
C. Allow the LPN to monitor vital signs only
D. Have the LPN prepare the blood and nurse administers
Answer: B. Refuse to delegate the task
Rationale: Blood transfusions are beyond the LPN scope in most states. The RN
is responsible for the administration. Delegating monitoring after RN initiates may
be appropriate, but initial administration cannot be delegated.
10. A nurse is providing teaching to a client who is prescribed warfarin. Which
statement indicates understanding?
A. “I will take aspirin for any pain I have.”
B. “I will eat a consistent amount of leafy green vegetables each day.”
C. “I do not need to have lab tests while on this medication.”
D. “I can stop the medication once I feel better.”
Answer: B. “I will eat a consistent amount of leafy green vegetables each day.”
Rationale: Vitamin K affects warfarin effectiveness. Consistency in intake helps
maintain therapeutic INR. Aspirin increases bleeding risk, labs are required, and
warfarin should not be stopped without provider guidance.
