ATI Comprehensive B Exam
Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? -
ANS Ask another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98
seconds and INR 1.8 - ANS Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which
indicates the client has a detached retina - ANS Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to
report to provider - ANS Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take - ANS Auscultate the apical pulse
and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool -
ANS Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine - ANS Broccoli, Yogurt, Cream Cheese
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse
document in the client's medical record? - ANS Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? - ANS A
10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain.
Can indicate peritonitis from a ruptured appendix.
,Community health nurse providing teaching on home safety for older adults - ANS Have grab bars
installed around your bathtub and toilet.
School age child with scald burns on both hands and wrists suspected abuse - ANS Contact child
protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion - ANS
Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational - ANS I will wear a supportive bra
overnight
Discharge instructions to client to received home oxygen therapy - ANS Wear clothing made with cotton
fabrics while oxygen is in use.
Preparing an educational session about advocacy to a group of nurses - ANS Advocacy is a leadership
role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output - ANS Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis - ANS Infuse IV fluids
Client teaching about the basal body temp method for birth control - ANS Your body temperature might
decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate
family to obtain consent - ANS Proceed with provision of medical care
, Client who has fluid volume overload. Which tasks can nurse delegate to UAP - ANS Measure the client's
daily weight
Checking for Chvostek's sign - ANS The nurse should assess for a Chvostek's sign by tapping the client's
facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that
indicates hypocalcemia.
Reviewing urinalysis report of client with acute glomerulonephritis expected findings - ANS Protein
Newly admitted child. Which of the following actions should the nurse include in the plan - ANS
Administer high dose antibiotic therapy
Client with cancer deciding between two treatment plans - ANS tell me more about your understanding
of the options.
Caring for a client receiving hemodalysis with AV fistula - ANS Auscultate the affected extremity for a
bruit
Oncology unit nurse is administering doxorubicin to breast cancer patient - ANS Inspect the client's
mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding
Hospice nurse consulting about receiving home services - ANS We can expect the hospice nurse to
provide support for us after our mother's death
Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure
about this now I'm afraid it's too risky - ANS You have the right to refuse to have the ECT even after you
have agreed to it
Discharge instructions about newborn care to a client 2 days postpartum - ANS I will cover my baby's
body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose.
Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? -
ANS Ask another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98
seconds and INR 1.8 - ANS Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which
indicates the client has a detached retina - ANS Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to
report to provider - ANS Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take - ANS Auscultate the apical pulse
and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool -
ANS Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine - ANS Broccoli, Yogurt, Cream Cheese
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse
document in the client's medical record? - ANS Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? - ANS A
10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain.
Can indicate peritonitis from a ruptured appendix.
,Community health nurse providing teaching on home safety for older adults - ANS Have grab bars
installed around your bathtub and toilet.
School age child with scald burns on both hands and wrists suspected abuse - ANS Contact child
protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion - ANS
Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational - ANS I will wear a supportive bra
overnight
Discharge instructions to client to received home oxygen therapy - ANS Wear clothing made with cotton
fabrics while oxygen is in use.
Preparing an educational session about advocacy to a group of nurses - ANS Advocacy is a leadership
role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output - ANS Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis - ANS Infuse IV fluids
Client teaching about the basal body temp method for birth control - ANS Your body temperature might
decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate
family to obtain consent - ANS Proceed with provision of medical care
, Client who has fluid volume overload. Which tasks can nurse delegate to UAP - ANS Measure the client's
daily weight
Checking for Chvostek's sign - ANS The nurse should assess for a Chvostek's sign by tapping the client's
facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that
indicates hypocalcemia.
Reviewing urinalysis report of client with acute glomerulonephritis expected findings - ANS Protein
Newly admitted child. Which of the following actions should the nurse include in the plan - ANS
Administer high dose antibiotic therapy
Client with cancer deciding between two treatment plans - ANS tell me more about your understanding
of the options.
Caring for a client receiving hemodalysis with AV fistula - ANS Auscultate the affected extremity for a
bruit
Oncology unit nurse is administering doxorubicin to breast cancer patient - ANS Inspect the client's
mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding
Hospice nurse consulting about receiving home services - ANS We can expect the hospice nurse to
provide support for us after our mother's death
Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure
about this now I'm afraid it's too risky - ANS You have the right to refuse to have the ECT even after you
have agreed to it
Discharge instructions about newborn care to a client 2 days postpartum - ANS I will cover my baby's
body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose.
