2023/2026 ATI COMPREHENSIVE EXIT EXAM WITH NGN | 180
VERIFIED Q and A
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.
Answer: A) Ensure the state health department has been notified.
Rationale: Lyme disease is a nationally notifiable infectious condition. Healthcare
providers are required to report cases to state health departments for
surveillance and prevention. Antitoxin is not used for Lyme disease; it is treated
with antibiotics. The other options do not address the legal and public health
reporting requirement.
2. 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.
Answer: B) Evaluate functioning of the suction device.
Rationale: The priority action is to assess the equipment. If the NG tube is not
functioning properly, it can lead to gastric distention and vomiting. The nurse
must evaluate the suction device first to determine if it's working correctly. The
,other actions are appropriate but should be done after assessing and correcting
the device function if needed.
3. A nurse is assisting with mass casualty triage after an explosion at a local
factory. Which of the following clients should the nurse identify as the priority?
• A) Client with massive head trauma.
• B) Client with full-thickness burns.
• C) Client with indications of hypovolemic shock.
• D) Client with an open fracture.
Answer: C) Client with indications of hypovolemic shock.
Rationale: In mass casualty triage (using the START system), the priority is the
client with an immediate, life-threatening but potentially survivable condition.
Hypovolemic shock is a major life threat. A client with massive head trauma or
full-thickness burns is likely to be classified as "black" (deceased/expectant) due
to the high likelihood of mortality. An open fracture is a "yellow" (delayed) injury.
4. A nurse is caring for a client who had abdominal surgery 24 hours ago. Which
action is the priority to reduce postoperative complications?
• A) Assess fluid intake every 24 hours.
• B) Ambulate the client three times a day.
• C) Assist with coughing and deep breathing exercises.
• D) Monitor the incision site for infection.
Answer: C) Assist with coughing and deep breathing exercises.
Rationale: Using the ABC (airway, breathing, circulation) approach, promoting
airway clearance by encouraging coughing and deep breathing helps prevent
pneumonia and other pulmonary complications, which are a significant risk post-
operatively. While the other options are important, they are not the highest
immediate priority.
5. A nurse is assessing a client in the PACU. Which of the following findings
indicates decreased cardiac output?
• A) Shivering.
, • B) Oliguria.
• C) Bradypnea.
• D) Constricted pupils.
Answer: B) Oliguria.
Rationale: Decreased cardiac output leads to reduced renal perfusion, which
results in oliguria (low urine output, typically <30 mL/hr). This is a key sign of
diminished organ perfusion. Shivering is a response to cold, bradypnea is slow
breathing, and constricted pupils can have various causes, but none are primary
indicators of decreased cardiac output.
Pharmacology
6. 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?
• A) Fibrinogen level.
• B) aPTT.
• C) INR.
• D) Platelet count.
Answer: C) INR.
Rationale: Warfarin therapy is monitored and dosed based on the International
Normalized Ratio (INR). The goal INR for most indications is between 2 and 3. The
aPTT is used to monitor heparin therapy, while fibrinogen and platelet counts are
used for other bleeding/clotting disorders.
7. A nurse is caring for a client who has a new prescription for clonidine. The
nurse should inform the client that which of the following findings is an adverse
effect of this medication?
• A) Diarrhea.
• B) Dry mouth.
• C) Photophobia.
, • D) Bruising.
Answer: B) Dry mouth.
Rationale: Clonidine is an antihypertensive that can cause dry mouth (xerostomia)
as a common adverse effect. It is also associated with constipation and
drowsiness. Diarrhea, photophobia, and bruising are not typical adverse effects of
this medication.
8. A client with heart failure is prescribed furosemide (Lasix) 40 mg IV. The nurse
should monitor for which adverse effect?
• A) Hyperkalemia.
• B) Hypokalemia.
• C) Hyponatremia.
• D) Hypercalcemia.
Answer: B) Hypokalemia.
Rationale: Furosemide is a loop diuretic that works in the ascending loop of Henle
to inhibit sodium and chloride reabsorption, leading to potassium wasting. This
can cause hypokalemia (low potassium), which can increase the risk of digoxin
toxicity and cardiac arrhythmias.
9. A client taking warfarin has an INR of 4.5 without bleeding. Which action
should the nurse take?
• A) Administer the next dose as scheduled.
• B) Administer vitamin K.
• C) Hold the dose and notify the provider.
• D) Increase the dose.
Answer: C) Hold the dose and notify the provider.
Rationale: The therapeutic INR range for warfarin is typically 2 to 3. An INR of 4.5
indicates a high risk of bleeding. The nurse should hold the dose and notify the
provider for further orders, which may include holding the dose and possibly
administering a low dose of vitamin K if there is a bleeding risk. Administering the
VERIFIED Q and A
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.
Answer: A) Ensure the state health department has been notified.
Rationale: Lyme disease is a nationally notifiable infectious condition. Healthcare
providers are required to report cases to state health departments for
surveillance and prevention. Antitoxin is not used for Lyme disease; it is treated
with antibiotics. The other options do not address the legal and public health
reporting requirement.
2. 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.
Answer: B) Evaluate functioning of the suction device.
Rationale: The priority action is to assess the equipment. If the NG tube is not
functioning properly, it can lead to gastric distention and vomiting. The nurse
must evaluate the suction device first to determine if it's working correctly. The
,other actions are appropriate but should be done after assessing and correcting
the device function if needed.
3. A nurse is assisting with mass casualty triage after an explosion at a local
factory. Which of the following clients should the nurse identify as the priority?
• A) Client with massive head trauma.
• B) Client with full-thickness burns.
• C) Client with indications of hypovolemic shock.
• D) Client with an open fracture.
Answer: C) Client with indications of hypovolemic shock.
Rationale: In mass casualty triage (using the START system), the priority is the
client with an immediate, life-threatening but potentially survivable condition.
Hypovolemic shock is a major life threat. A client with massive head trauma or
full-thickness burns is likely to be classified as "black" (deceased/expectant) due
to the high likelihood of mortality. An open fracture is a "yellow" (delayed) injury.
4. A nurse is caring for a client who had abdominal surgery 24 hours ago. Which
action is the priority to reduce postoperative complications?
• A) Assess fluid intake every 24 hours.
• B) Ambulate the client three times a day.
• C) Assist with coughing and deep breathing exercises.
• D) Monitor the incision site for infection.
Answer: C) Assist with coughing and deep breathing exercises.
Rationale: Using the ABC (airway, breathing, circulation) approach, promoting
airway clearance by encouraging coughing and deep breathing helps prevent
pneumonia and other pulmonary complications, which are a significant risk post-
operatively. While the other options are important, they are not the highest
immediate priority.
5. A nurse is assessing a client in the PACU. Which of the following findings
indicates decreased cardiac output?
• A) Shivering.
, • B) Oliguria.
• C) Bradypnea.
• D) Constricted pupils.
Answer: B) Oliguria.
Rationale: Decreased cardiac output leads to reduced renal perfusion, which
results in oliguria (low urine output, typically <30 mL/hr). This is a key sign of
diminished organ perfusion. Shivering is a response to cold, bradypnea is slow
breathing, and constricted pupils can have various causes, but none are primary
indicators of decreased cardiac output.
Pharmacology
6. 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?
• A) Fibrinogen level.
• B) aPTT.
• C) INR.
• D) Platelet count.
Answer: C) INR.
Rationale: Warfarin therapy is monitored and dosed based on the International
Normalized Ratio (INR). The goal INR for most indications is between 2 and 3. The
aPTT is used to monitor heparin therapy, while fibrinogen and platelet counts are
used for other bleeding/clotting disorders.
7. A nurse is caring for a client who has a new prescription for clonidine. The
nurse should inform the client that which of the following findings is an adverse
effect of this medication?
• A) Diarrhea.
• B) Dry mouth.
• C) Photophobia.
, • D) Bruising.
Answer: B) Dry mouth.
Rationale: Clonidine is an antihypertensive that can cause dry mouth (xerostomia)
as a common adverse effect. It is also associated with constipation and
drowsiness. Diarrhea, photophobia, and bruising are not typical adverse effects of
this medication.
8. A client with heart failure is prescribed furosemide (Lasix) 40 mg IV. The nurse
should monitor for which adverse effect?
• A) Hyperkalemia.
• B) Hypokalemia.
• C) Hyponatremia.
• D) Hypercalcemia.
Answer: B) Hypokalemia.
Rationale: Furosemide is a loop diuretic that works in the ascending loop of Henle
to inhibit sodium and chloride reabsorption, leading to potassium wasting. This
can cause hypokalemia (low potassium), which can increase the risk of digoxin
toxicity and cardiac arrhythmias.
9. A client taking warfarin has an INR of 4.5 without bleeding. Which action
should the nurse take?
• A) Administer the next dose as scheduled.
• B) Administer vitamin K.
• C) Hold the dose and notify the provider.
• D) Increase the dose.
Answer: C) Hold the dose and notify the provider.
Rationale: The therapeutic INR range for warfarin is typically 2 to 3. An INR of 4.5
indicates a high risk of bleeding. The nurse should hold the dose and notify the
provider for further orders, which may include holding the dose and possibly
administering a low dose of vitamin K if there is a bleeding risk. Administering the
