Q&A | ATI Nursing Exam
1. Which of the following actions should the charge nurse take when assigning a float RN
from the postpartum unit to a medical-surgical unit?
A) Assign the float RN to a client with diabetic ketoacidosis requiring insulin titration
B) Assign the float RN to a client who is postoperative day 2 following an appendectomy and
is stable
C) Assign the float RN to a client with a chest tube for a pneumothorax
D) Assign the float RN to a client receiving IV heparin for a deep vein thrombosis
Correct Answer: Assign the float RN to a client who is postoperative day 2 following an
appendectomy and is stable
Rationale: When delegating to a float RN, the nurse should assign clients with stable,
predictable conditions that match the RN's competency. A stable postoperative client is
appropriate. Clients with DKA, chest tubes, or IV heparin require specialized knowledge
outside the float RN's typical postpartum experience.
2. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which
action is most important to reduce the risk of catheter-associated urinary tract infection
(CAUTI)?
A) Use sterile gloves and a sterile drape during insertion
B) Apply lubricant to the catheter tip before insertion
C) Perform perineal care with soap and water before insertion
D) Secure the catheter to the client's thigh after insertion
Correct Answer: Use sterile gloves and a sterile drape during insertion
,Rationale: CAUTI prevention begins with aseptic technique during insertion. While all
options are part of proper catheter care, maintaining sterile technique during insertion is the
most critical intervention to prevent introducing pathogens into the bladder.
3. A client who is taking warfarin has an International Normalized Ratio (INR) of 5.8. Which
medication should the nurse anticipate administering?
A) Protamine sulfate
B) Vitamin K
C) Naloxone
D) Flumazenil
Correct Answer: Vitamin K
Rationale: An INR of 5.8 is significantly elevated, indicating a high risk of bleeding. Vitamin K
is the specific antidote for warfarin and is administered to reverse its anticoagulant effects.
Protamine sulfate reverses heparin, naloxone reverses opioids, and flumazenil reverses
benzodiazepines.
4. A charge nurse is assigning rooms for four clients. Which client should be placed in a
private room?
A) A client with pneumonia
B) A client with methicillin-resistant Staphylococcus aureus (MRSA)
C) A client with a diabetic foot ulcer
D) A client with chronic obstructive pulmonary disease (COPD)
Correct Answer: A client with methicillin-resistant Staphylococcus aureus (MRSA)
Rationale: MRSA requires contact isolation to prevent transmission. A private room is
essential to contain the infection. Pneumonia may require droplet precautions, but MRSA-
contact is the priority for single-room assignment to protect other clients.
, 5. Before administering intravenous (IV) dopamine, which assessment should the nurse
perform as the priority?
A) Lung sounds
B) Blood pressure
C) Level of consciousness
D) Urine output
Correct Answer: Blood pressure
Rationale: Dopamine is a vasopressor used to treat hypotension. The priority assessment
before administration is blood pressure to ensure the medication is indicated and to
establish a baseline for monitoring effectiveness. Hypotension is the primary indication for
dopamine therapy.
6. A nurse is caring for a client with heart failure who reports sudden shortness of breath,
cough with pink frothy sputum, and anxiety. Vital signs are BP 168/94, HR 118, RR 32. Which
action should the nurse take first?
A) Administer a loop diuretic as prescribed
B) Place the client in high-Fowler's position
C) Notify the healthcare provider
D) Apply oxygen via nasal cannula
Correct Answer: Place the client in high-Fowler's position
Rationale: The client is experiencing acute pulmonary edema. The priority intervention is to
place the client in high-Fowler's position to reduce venous return, decrease preload, and
improve ventilation. Oxygen and diuretics are important but follow positioning to optimize
respiratory status.
7. A nurse is preparing to administer a blood transfusion. Which finding requires the nurse to
stop the transfusion immediately?