ATI Comprehensive Exit Exam
1. A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take
a. Ensure the state health department has been notified
b. Administer antitoxin
c. Educate the family to avoid sharing personal belongings
d. Assess for skin necrosis
2. A nurse is caring for a client who has been admitted to the hospital. Select 5 actions the nurse
should take.
a. Provide frequent rest periods for the client
b. Restrict the client’s sodium intake.
c. Advise the client to avoid the use of soap and alcohol-based lotions
d. Instruct the client to avoid blowing their nose forcefully
e. Assess the client’s level of orientation
f. Place the client on a low carbohydrate diet
g. Place the client under contact isolation
3. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has
vomited. Which of the following actions should the nurse perform first?
a. Administer an antiemetic medication.
b. Evaluate functioning of the suction device.
c. Provide oral hygiene care.
d. Replace the NG tube.
4. While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client's continuous passive motion (CPM) device. Which of the following actions should the
nurse take first?
a. Initiate a requisition for a replacement CPM device.
b. Report the defect to the equipment maintenance staff.
c. Remove the device from the room.
d. Ensure the device inspection sticker is current.
5. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections.
Which of the following interventions should the nurse include in the plan?
a. Wear loose-fitting underwear.
b. Take a bubble bath after intercourse.
c. Drink four 240 mL (8 02) glasses of water each day.
d. Void every 5 to 6 hr during the day.
6. A nurse is caring for a newborn. The patient is at risk for developing?
Vital Signs
0630 → Newborn delivered via cesarean birth under spinal anesthesia at 0630. Amniotic
fluid clear.
0631→ 1-min Apgar score 7
0636 → 5-min Apgar score 9Newborn transferred to nursery.
0640 → Temperature 36.7° C (98.1° F), HR 154/min RR 68/min, BP 72/48 with mild grunting.
Weight 4200 gm (9 Ib 4 02), head circumference 35.5 cm (14in)
, 0650 → HR 156/min, RR 72/min, with mild grunting
0700 → Temperature 37° C (98.6° F) HR 156/min, RR 76/min, with moderate grunting and
mild intercostal retractions.
a. Hypoglycemia
b. Bronchopulmonary dysplasia
c. Transient tachypnea of the newborn
d. Tachycardia
7. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the
following actions should the nurse take when pouring the sterile solution?
a. Remove the cap and place it sterile side up on a clean surface.
b. Place sterile gauze over areas of spilled solution within the sterile field.
c. Hold the bottle in the center of the sterile field when pouring the solution.
d. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
8. A nurse is caring for an infant who has gastroenteritis. Which of the follow- ing assessment
findings should the nurse report to the provider?
a. Pale and a 24-hr fluid deficit of 30 mL
b. Sunken fontanels and dry mucous membranes
c. Decreased appetite and irritability
d. Temperature 38° C (100.4° F) and pulse rate 124/min
G. A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching?
a. Hypertension
b. Fibromyalgia
c. Renal calculi
d. Fibrocystic breast disease
10. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates an understanding of
the teaching?
a. "I can continue to take St. John's wort while taking this medication."
b. "I know it will be a couple of weeks before the medication helps me feel better."
c. "I expect this medication to raise my blood pressure."
d. "I should take this medication on an empty stomach."
11. A nurse is caring for a client who is immobile. Which of the following interventions is
appropriate to prevent contracture?
a. Position a pillow under the client's knees.
b. Place a towel roll under the client's neck.
c. Align a trochanter wedge between the client's legs.
d. Apply an orthotic to the client's foot.
12. A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following
interventions should the nurse anticipate?
, a. Initiate continuous bladder irrigation.
b. Administer a fluid bolus.
c. Clamp the catheter tubing for 30 min.
d. Obtain a urine specimen for culture and sensitivity.
13. A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the
client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to
obtain the prescription for the warfarin?
a. Fibrinogen level
b. aPTT
c. INR
d. Platelet
14. A nurse is assessing a client who is taking haloperidol and is experiencing pseudo-
parkinsonism. Which of the following findings should the nurse document as a manifestation of
pseudo-parkinsonism?
a. Serpentine limb movement
b. Shuffling gait
c. Nonreactive pupils
d. Smacking lips
15. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client?
a. Posting swallowing precautions at the head of the client's bed
b. Noting changes in the treatment plan in the client's medical record
c. Recording the client's progress in the nurses' notes
d. Having interdisciplinary team meetings for the client on a regular basis
16. A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse
recommend to promote independence in eating?
a. Banana slices
b. Grapes
c. Hot dog
d. Popcorn
17. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the
community. Which of the following actions should the nurse plan to take?
a. Act as a liaison between the facility and the media.
b. Recommend to the provider specific acute care clients for discharge.
c. Determine the medical needs of incoming clients through the emergency department.
d. Call in additional medical-surgical unit nursing care staff.
18. A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
a. A client who is scheduled for a procedure in 1 hr
b. A client who received a pain medication 30 min ago for postoperative pain
c. A client who was just given a glass of orange juice for a low blood glucose level
d. A client who has 100 mL of fluid remaining in his IV bag
, 1G. A nurse is performing postmortem care for a recently deceased client prior to the client's family
visit. Which of the following actions should the nurse plan to take?
a. Cross the client's arms across their chest.
b. Hold the client's eyes shut for a few seconds.
c. Place the client in a high-Fowler's position.
d. Remove the client's dentures from their mouth.
20. A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices."
Which of the following responses is the priority for the nurse to state?
a. "What are the voices telling you?"
b. "I realize the voices are real to you, but | don't hear anything."
c. "Have you taken your medication today?"
d. "How long have you been hearing the voices?"
21. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse
should recognize which of the following findings as an indication that the medication has been
effective?
a. Increased blood pressure
b. Weight loss
c. Decreased inflammation
d. Decreased pain
22. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the
nurse should follow to perform suctioning. (Move the steps into the box on the right, placing
them in the order of performance. Use all the steps.)
- Apply suction while rotating the catheter
- Rinse the catheter to remove secretions.
- Don sterile gloves.
- Insert the catheter during the client's inspiration.
- Turn on the suction and set the pressure
1) → Turn on the suction and set the pressure.
2) → Don sterile gloves.
3) → Insert the catheter during the client's inspiration.
4) → Apply suction while rotating the catheter.
5) → Rinse the catheter to remove secretions.
23. A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which
of the following actions should the nurse take?
a. Send the unsigned informed consent form to the facility's risk manager.
b. Determine if the client's health care surrogate is aware of the risks and benefits of the
procedure.
c. Ensure that the client's family supports the provider's decision for surgery.
d. Determine if the procedure is medically necessary for the client.
24. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if
the medication can be given 2 hr earlier. Which of the following statements should the nurse
make?
1. A home health nurse is caring for a child who has Lyme disease. Which of the following is an
appropriate action for the nurse to take
a. Ensure the state health department has been notified
b. Administer antitoxin
c. Educate the family to avoid sharing personal belongings
d. Assess for skin necrosis
2. A nurse is caring for a client who has been admitted to the hospital. Select 5 actions the nurse
should take.
a. Provide frequent rest periods for the client
b. Restrict the client’s sodium intake.
c. Advise the client to avoid the use of soap and alcohol-based lotions
d. Instruct the client to avoid blowing their nose forcefully
e. Assess the client’s level of orientation
f. Place the client on a low carbohydrate diet
g. Place the client under contact isolation
3. A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has
vomited. Which of the following actions should the nurse perform first?
a. Administer an antiemetic medication.
b. Evaluate functioning of the suction device.
c. Provide oral hygiene care.
d. Replace the NG tube.
4. While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client's continuous passive motion (CPM) device. Which of the following actions should the
nurse take first?
a. Initiate a requisition for a replacement CPM device.
b. Report the defect to the equipment maintenance staff.
c. Remove the device from the room.
d. Ensure the device inspection sticker is current.
5. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections.
Which of the following interventions should the nurse include in the plan?
a. Wear loose-fitting underwear.
b. Take a bubble bath after intercourse.
c. Drink four 240 mL (8 02) glasses of water each day.
d. Void every 5 to 6 hr during the day.
6. A nurse is caring for a newborn. The patient is at risk for developing?
Vital Signs
0630 → Newborn delivered via cesarean birth under spinal anesthesia at 0630. Amniotic
fluid clear.
0631→ 1-min Apgar score 7
0636 → 5-min Apgar score 9Newborn transferred to nursery.
0640 → Temperature 36.7° C (98.1° F), HR 154/min RR 68/min, BP 72/48 with mild grunting.
Weight 4200 gm (9 Ib 4 02), head circumference 35.5 cm (14in)
, 0650 → HR 156/min, RR 72/min, with mild grunting
0700 → Temperature 37° C (98.6° F) HR 156/min, RR 76/min, with moderate grunting and
mild intercostal retractions.
a. Hypoglycemia
b. Bronchopulmonary dysplasia
c. Transient tachypnea of the newborn
d. Tachycardia
7. A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the
following actions should the nurse take when pouring the sterile solution?
a. Remove the cap and place it sterile side up on a clean surface.
b. Place sterile gauze over areas of spilled solution within the sterile field.
c. Hold the bottle in the center of the sterile field when pouring the solution.
d. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
8. A nurse is caring for an infant who has gastroenteritis. Which of the follow- ing assessment
findings should the nurse report to the provider?
a. Pale and a 24-hr fluid deficit of 30 mL
b. Sunken fontanels and dry mucous membranes
c. Decreased appetite and irritability
d. Temperature 38° C (100.4° F) and pulse rate 124/min
G. A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching?
a. Hypertension
b. Fibromyalgia
c. Renal calculi
d. Fibrocystic breast disease
10. A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for amitriptyline. Which of the following statements by the client indicates an understanding of
the teaching?
a. "I can continue to take St. John's wort while taking this medication."
b. "I know it will be a couple of weeks before the medication helps me feel better."
c. "I expect this medication to raise my blood pressure."
d. "I should take this medication on an empty stomach."
11. A nurse is caring for a client who is immobile. Which of the following interventions is
appropriate to prevent contracture?
a. Position a pillow under the client's knees.
b. Place a towel roll under the client's neck.
c. Align a trochanter wedge between the client's legs.
d. Apply an orthotic to the client's foot.
12. A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following
interventions should the nurse anticipate?
, a. Initiate continuous bladder irrigation.
b. Administer a fluid bolus.
c. Clamp the catheter tubing for 30 min.
d. Obtain a urine specimen for culture and sensitivity.
13. A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the
client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to
obtain the prescription for the warfarin?
a. Fibrinogen level
b. aPTT
c. INR
d. Platelet
14. A nurse is assessing a client who is taking haloperidol and is experiencing pseudo-
parkinsonism. Which of the following findings should the nurse document as a manifestation of
pseudo-parkinsonism?
a. Serpentine limb movement
b. Shuffling gait
c. Nonreactive pupils
d. Smacking lips
15. A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a stroke. Which of the following actions by the nurse best promotes communication
among staff caring for the client?
a. Posting swallowing precautions at the head of the client's bed
b. Noting changes in the treatment plan in the client's medical record
c. Recording the client's progress in the nurses' notes
d. Having interdisciplinary team meetings for the client on a regular basis
16. A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse
recommend to promote independence in eating?
a. Banana slices
b. Grapes
c. Hot dog
d. Popcorn
17. A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the
community. Which of the following actions should the nurse plan to take?
a. Act as a liaison between the facility and the media.
b. Recommend to the provider specific acute care clients for discharge.
c. Determine the medical needs of incoming clients through the emergency department.
d. Call in additional medical-surgical unit nursing care staff.
18. A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
a. A client who is scheduled for a procedure in 1 hr
b. A client who received a pain medication 30 min ago for postoperative pain
c. A client who was just given a glass of orange juice for a low blood glucose level
d. A client who has 100 mL of fluid remaining in his IV bag
, 1G. A nurse is performing postmortem care for a recently deceased client prior to the client's family
visit. Which of the following actions should the nurse plan to take?
a. Cross the client's arms across their chest.
b. Hold the client's eyes shut for a few seconds.
c. Place the client in a high-Fowler's position.
d. Remove the client's dentures from their mouth.
20. A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices."
Which of the following responses is the priority for the nurse to state?
a. "What are the voices telling you?"
b. "I realize the voices are real to you, but | don't hear anything."
c. "Have you taken your medication today?"
d. "How long have you been hearing the voices?"
21. A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse
should recognize which of the following findings as an indication that the medication has been
effective?
a. Increased blood pressure
b. Weight loss
c. Decreased inflammation
d. Decreased pain
22. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the
nurse should follow to perform suctioning. (Move the steps into the box on the right, placing
them in the order of performance. Use all the steps.)
- Apply suction while rotating the catheter
- Rinse the catheter to remove secretions.
- Don sterile gloves.
- Insert the catheter during the client's inspiration.
- Turn on the suction and set the pressure
1) → Turn on the suction and set the pressure.
2) → Don sterile gloves.
3) → Insert the catheter during the client's inspiration.
4) → Apply suction while rotating the catheter.
5) → Rinse the catheter to remove secretions.
23. A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which
of the following actions should the nurse take?
a. Send the unsigned informed consent form to the facility's risk manager.
b. Determine if the client's health care surrogate is aware of the risks and benefits of the
procedure.
c. Ensure that the client's family supports the provider's decision for surgery.
d. Determine if the procedure is medically necessary for the client.
24. A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if
the medication can be given 2 hr earlier. Which of the following statements should the nurse
make?
