THE ULTIMATE ATI COMPREHENSIVE
EXIT EXAM REVIEW: Q&A COVERING
SAFE NURSING CARE,
PHARMACOLOGY, PRIORITIZATION,
AND NGN CASE STUDIES
A patient's father died a week ago. Both the patient and the patient's
spouse talk about the death. The patient's spouse is experiencing
headaches and fatigue. The patient is having trouble sleeping, has no
appetite, and gets choked up most of the time. How should the nurse
interpret these findings as the basis for a follow-up assessment?
Answer: Both the patient and the spouse are likely grieving.
Rationale: Symptoms of normal grief include headache, fatigue, insomnia,
appetite disturbance, and a choking sensation. Different people manifest
different symptoms. There is no data to support the spouse being angry or
malingering. Denial is assessed when the person cannot accept the loss;
both talked about the loss .
A nurse is documenting end-of-life care. Which information will the nurse
include in the patient's electronic medical record? (Select all that apply.)
Answer: Time and date of death, location of body identification tags, time
of body transfer and destination.
,Rationale: Documentation of end-of-life care includes the time and date of
death, location of body identification tags, time of body transfer and
destination, and personal articles left on and secured to the body. The
reason for death is a medical judgment and not a nursing judgment. How
ethically the family grieved is judgmental and does not belong in the chart .
A home health nurse is performing a home assessment for safety. Which
comment by the patient will cause the nurse to follow up?
Answer: "When it is cold outside in the winter, I will use a non-vented
furnace."
Rationale: Using a non-vented heater introduces carbon monoxide into the
environment and decreases the available oxygen for human consumption.
The nurse should follow up to correct this behavior. Checking the chimney
and heater, changing batteries on the detector, and following up on
symptoms such as dizziness, nausea, and fatigue are all safe statements .
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. What
action should the nurse take before administering the medication?
Answer: Checking the client's blood pressure.
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is postural
hypotension. Therefore the nurse would check the client's blood pressure
immediately before administering each dose .
A client is scheduled to undergo an upper gastrointestinal (GI) series. Which
client statement indicates a need for further teaching?
Answer: "I need to drink citrate of magnesia the night before the test and
give myself a Fleet enema on the morning of the test."
,Rationale: An upper GI series involves visualization of the esophagus,
duodenum, and upper jejunum using a contrast medium (usually barium).
No special preparation is necessary except that NPO status must be
maintained for 8 hours before the test. After the test, a laxative is
prescribed to hasten elimination of the barium .
A nurse on the evening shift notes that the dose of a prescribed medication
is higher than the normal dose. The physician is off for the night and will be
available in the morning. What should the nurse do?
Answer: Ask the Answering service to contact the on-call physician.
Rationale: The nurse has a duty to protect the client from harm. A nurse
who believes that a physician's prescription may be in error is responsible
for clarifying the prescription before carrying it out. The nurse would not
administer the medication or wait until the next morning .
An emergency department nurse is monitoring a client with suspected
acute myocardial infarction (MI) who is awaiting transfer. The nurse notes
the sudden onset of premature ventricular contractions (PVCs) on the
monitor and determines that the PVCs are not resulting in perfusion. What
is the most appropriate action?
Answer: Asking the ED physician to check the client.
Rationale: PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs themselves
because the decreased stroke volume of the premature beats may decrease
peripheral perfusion. In acute MI, PVCs may be warning dysrhythmias,
possibly heralding the onset of ventricular tachycardia or ventricular
fibrillation .
, A client scheduled for electroconvulsive therapy (ECT) at 1 p.m. routinely
takes an oral antihypertensive medication each morning. How should the
nurse administer the medication?
Answer: Administer the antihypertensive with a small sip of water.
Rationale: General anesthesia is required for ECT, so NPO status is imposed
for 6 to 8 hours before treatment to help prevent aspiration. Exceptions
include clients who routinely receive cardiac medications, antihypertensive
agents, or histamine blockers, which should be administered several hours
before treatment with a small sip of water .
A nurse is caring for a client who has been admitted to the hospital. The
client reports loss of appetite, shortness of breath for the past month,
weakness, abdominal pain, severe itching, and mood changes. The client
has a 10-year history of alcohol use disorder. Assessment findings include
abdominal bloating, redness of the palms, excoriation areas on the upper
thorax and shoulders, and yellow sclera. Which condition is the client most
likely experiencing?
Answer: Alcoholic cirrhosis with hepatic encephalopathy.
Rationale: The client's findings are classic for alcoholic cirrhosis with
hepatic encephalopathy: jaundice (yellow sclera), ascites (abdominal
bloating), palmar erythema (redness of palms), pruritus (itching with
excoriations), and confusion/disorientation (hepatic encephalopathy). The
history of alcohol use disorder further supports this diagnosis .
A home health nurse is caring for a child who has Lyme disease. Which
action should the nurse take?
Answer: Ensure the state health department has been notified.
EXIT EXAM REVIEW: Q&A COVERING
SAFE NURSING CARE,
PHARMACOLOGY, PRIORITIZATION,
AND NGN CASE STUDIES
A patient's father died a week ago. Both the patient and the patient's
spouse talk about the death. The patient's spouse is experiencing
headaches and fatigue. The patient is having trouble sleeping, has no
appetite, and gets choked up most of the time. How should the nurse
interpret these findings as the basis for a follow-up assessment?
Answer: Both the patient and the spouse are likely grieving.
Rationale: Symptoms of normal grief include headache, fatigue, insomnia,
appetite disturbance, and a choking sensation. Different people manifest
different symptoms. There is no data to support the spouse being angry or
malingering. Denial is assessed when the person cannot accept the loss;
both talked about the loss .
A nurse is documenting end-of-life care. Which information will the nurse
include in the patient's electronic medical record? (Select all that apply.)
Answer: Time and date of death, location of body identification tags, time
of body transfer and destination.
,Rationale: Documentation of end-of-life care includes the time and date of
death, location of body identification tags, time of body transfer and
destination, and personal articles left on and secured to the body. The
reason for death is a medical judgment and not a nursing judgment. How
ethically the family grieved is judgmental and does not belong in the chart .
A home health nurse is performing a home assessment for safety. Which
comment by the patient will cause the nurse to follow up?
Answer: "When it is cold outside in the winter, I will use a non-vented
furnace."
Rationale: Using a non-vented heater introduces carbon monoxide into the
environment and decreases the available oxygen for human consumption.
The nurse should follow up to correct this behavior. Checking the chimney
and heater, changing batteries on the detector, and following up on
symptoms such as dizziness, nausea, and fatigue are all safe statements .
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. What
action should the nurse take before administering the medication?
Answer: Checking the client's blood pressure.
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is postural
hypotension. Therefore the nurse would check the client's blood pressure
immediately before administering each dose .
A client is scheduled to undergo an upper gastrointestinal (GI) series. Which
client statement indicates a need for further teaching?
Answer: "I need to drink citrate of magnesia the night before the test and
give myself a Fleet enema on the morning of the test."
,Rationale: An upper GI series involves visualization of the esophagus,
duodenum, and upper jejunum using a contrast medium (usually barium).
No special preparation is necessary except that NPO status must be
maintained for 8 hours before the test. After the test, a laxative is
prescribed to hasten elimination of the barium .
A nurse on the evening shift notes that the dose of a prescribed medication
is higher than the normal dose. The physician is off for the night and will be
available in the morning. What should the nurse do?
Answer: Ask the Answering service to contact the on-call physician.
Rationale: The nurse has a duty to protect the client from harm. A nurse
who believes that a physician's prescription may be in error is responsible
for clarifying the prescription before carrying it out. The nurse would not
administer the medication or wait until the next morning .
An emergency department nurse is monitoring a client with suspected
acute myocardial infarction (MI) who is awaiting transfer. The nurse notes
the sudden onset of premature ventricular contractions (PVCs) on the
monitor and determines that the PVCs are not resulting in perfusion. What
is the most appropriate action?
Answer: Asking the ED physician to check the client.
Rationale: PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs themselves
because the decreased stroke volume of the premature beats may decrease
peripheral perfusion. In acute MI, PVCs may be warning dysrhythmias,
possibly heralding the onset of ventricular tachycardia or ventricular
fibrillation .
, A client scheduled for electroconvulsive therapy (ECT) at 1 p.m. routinely
takes an oral antihypertensive medication each morning. How should the
nurse administer the medication?
Answer: Administer the antihypertensive with a small sip of water.
Rationale: General anesthesia is required for ECT, so NPO status is imposed
for 6 to 8 hours before treatment to help prevent aspiration. Exceptions
include clients who routinely receive cardiac medications, antihypertensive
agents, or histamine blockers, which should be administered several hours
before treatment with a small sip of water .
A nurse is caring for a client who has been admitted to the hospital. The
client reports loss of appetite, shortness of breath for the past month,
weakness, abdominal pain, severe itching, and mood changes. The client
has a 10-year history of alcohol use disorder. Assessment findings include
abdominal bloating, redness of the palms, excoriation areas on the upper
thorax and shoulders, and yellow sclera. Which condition is the client most
likely experiencing?
Answer: Alcoholic cirrhosis with hepatic encephalopathy.
Rationale: The client's findings are classic for alcoholic cirrhosis with
hepatic encephalopathy: jaundice (yellow sclera), ascites (abdominal
bloating), palmar erythema (redness of palms), pruritus (itching with
excoriations), and confusion/disorientation (hepatic encephalopathy). The
history of alcohol use disorder further supports this diagnosis .
A home health nurse is caring for a child who has Lyme disease. Which
action should the nurse take?
Answer: Ensure the state health department has been notified.
