ATI COMPREHENSIVE RETAKE 2023 EXAM 180 QUESTIONS AND DETAILED
ANSWERS//ALREADY GRADED A+
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit.Which of the following
actions should the nurse take?
A. Assess the child for Koplik spots.
B. Assign the child to a negative air pressure room.
C. Use droplet precautions when caring for the child.
D. Administer aspirin to the child for fever. - answer-Use droplet precautions when caring for the child.
Using droplet precautions when caring for the child is appropriate because varicella is highly contagious
and spreads through respiratory droplets. Droplet precautions involve wearing a mask and maintaining a
safe distance from the infected individual, which helps prevent the spread of the virus to others.
An older client with a history of heart failure is admitted with influenza and requests assistance to sit up
in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and
gloves to assist the client. Which action should the nurse take?
A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
C. Assign the UAP to provide care for another client and assume full care of the client.
D. Review the need for the UAP to wear a face mask while in close contact with the client. -
answerReview the need for the UAP to wear a face mask while in close contact with the client.
A nurse is assessing a client who has a chest tube with a water seal drainage system.Upon assessment,
the nurse notes tidaling in the water seal.Which of the following is an explanation for the tidaling? A.
The lung has re-expanded.
B. There is a loop of tubing below the drainage system.
C. The system is working properly.
D. The tubing is partially obstructed by clots. - answer-There is a loop of tubing below the drainage
system
This is the correct answer. Tidaling in the water seal chamber of a chest drainage system is normal and
indicates proper functioning. It occurs because of the fluctuation of intrathoracic pressure with the
client's breathing. If there is a loop of tubing below the drainage system, it prevents the fluid from
returning to the patient and maintains the water seal.
,A charge nurse is teaching a newly licensed nurse about medication administration.Which of the
following information should the charge nurse include?
A. Avoid preparing medications for more than two clients at one time.
B. Inform clients about the action of each medication prior to administration.
C. Read medication labels at least two times prior to administration.
D. Complete an incident report if a client vomits after taking a medication. - answer-Read medication
labels at least two times prior to administration.
This is the correct answer. Reading medication labels at least two times before administration is
essential to ensure the right medication, dosage, route, and time. It is a crucial step in medication safety
protocols and helps prevent medication errors.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets
20 minutes ago.The client is lethargic and has a respiratory rate of 10/min.After securing the client's
airway and initiating an IV, which of the following actions should the nurse take next? A. Evaluate the
client for further suicidal behavior.
B. Administer flumazenil to the client.
C. Monitor the client's IV site for thrombophlebitis.
D. Initiate seizure precautions for the client. - answer-Initiate seizure precautions for the client.
This is the correct answer. Initiating seizure precautions is crucial in this situation because
benzodiazepine overdose can lead to seizures, especially during the recovery phase as the drug's effects
wear off. Implementing seizure precautions, such as padding the siderails and ensuring a safe
environment, helps prevent injury during a seizure episode.
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol.Which
of the following adverse effects should the nurse instruct the client to report to the provider? A.
Weight gain.
B. Dry mouth.
C. Shuffling gait.
D. Sedation. - answer-Shuffling gait.
This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with
the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a
shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it
may indicate the development of a serious neurological condition called tardive dyskinesia.
,A nurse is caring for an adolescent client who has cystic fibrosis.Which of the following actions should
the nurse instruct the client to take prior to initiating postural drainage? A. Eat a meal.
B. Take pancrelipase.
C. Use an albuterol inhaler.
D. Complete oral hygiene. - answer-Complete oral hygiene.
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.Which of the
following examples should the nurse include in the teaching as an example of malpractice? A.
Administering potassium via IV bolus.
B. Leaving a nasogastric tube clamped after administering oral medication.
C. Placing a yellow bracelet on a client who is at risk for falls.
D. Documenting communication with a provider in the progress notes of the client's medical record. -
answer-Administering potassium via IV bolus.
A nurse is performing a neurological examination on a client as part of a complete physical
assessment.The nurse should identify that cranial nerve XI is intact when the client performs which of
the following actions?
A. Sticks his tongue out.
B. Frowns symmetrically.
C. Identifies a sour taste.
D. Shrugs his shoulders. - answer-Shrugs his shoulders.
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open
system.Which of the following interventions should the nurse include in the plan of care? A. Maintain
bed elevation at 20 degrees.
B. Flush the tubing with 30 mL of water every 4 hr.
C. Check for gastric residual every 12 hr.
D. Place enough formula in the container to last 18 hr. - answer-Maintain bed elevation at 20 degrees.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the
therapeutic relationship.Which of the following statements should the nurse make during this phase?
, A. "We should establish our roles in the initial session."
B. "Let me show you simple relaxation exercises to manage stress."
C. "Let's talk about how you can change your response to stress."
D. "We should discuss resources to implement in your daily life." . - answer-"We should establish our
roles in the initial session."
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart
rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting
effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the
absence of distinct P waves on the ECG.
A nurse is assessing the fontanels of an 8-month-old infant.Which of the following findings should the
nurse recognize as an expected finding?
A. The anterior fontanel is open.
B. The posterior fontanel is open.
C. Both fontanels show molding.
D. Both fontanels are the same size. - answer-The anterior fontanel is open.
The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the
baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age.
It is a normal finding in an 8-month-old infant.
A nurse is planning care for a client who has acute appendicitis.Which of the following actions should the
nurse plan to take?
A. Administer a laxative to the client.
B. Keep the client on NPO status.
C. Place the client's head of bed flat.
D. Apply heat to the client's abdomen. - answer-Keep the client on NPO status.
ANSWERS//ALREADY GRADED A+
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit.Which of the following
actions should the nurse take?
A. Assess the child for Koplik spots.
B. Assign the child to a negative air pressure room.
C. Use droplet precautions when caring for the child.
D. Administer aspirin to the child for fever. - answer-Use droplet precautions when caring for the child.
Using droplet precautions when caring for the child is appropriate because varicella is highly contagious
and spreads through respiratory droplets. Droplet precautions involve wearing a mask and maintaining a
safe distance from the infected individual, which helps prevent the spread of the virus to others.
An older client with a history of heart failure is admitted with influenza and requests assistance to sit up
in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and
gloves to assist the client. Which action should the nurse take?
A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.
B. Remind the UAP to apply a fitted respirator mask before entering the client's room.
C. Assign the UAP to provide care for another client and assume full care of the client.
D. Review the need for the UAP to wear a face mask while in close contact with the client. -
answerReview the need for the UAP to wear a face mask while in close contact with the client.
A nurse is assessing a client who has a chest tube with a water seal drainage system.Upon assessment,
the nurse notes tidaling in the water seal.Which of the following is an explanation for the tidaling? A.
The lung has re-expanded.
B. There is a loop of tubing below the drainage system.
C. The system is working properly.
D. The tubing is partially obstructed by clots. - answer-There is a loop of tubing below the drainage
system
This is the correct answer. Tidaling in the water seal chamber of a chest drainage system is normal and
indicates proper functioning. It occurs because of the fluctuation of intrathoracic pressure with the
client's breathing. If there is a loop of tubing below the drainage system, it prevents the fluid from
returning to the patient and maintains the water seal.
,A charge nurse is teaching a newly licensed nurse about medication administration.Which of the
following information should the charge nurse include?
A. Avoid preparing medications for more than two clients at one time.
B. Inform clients about the action of each medication prior to administration.
C. Read medication labels at least two times prior to administration.
D. Complete an incident report if a client vomits after taking a medication. - answer-Read medication
labels at least two times prior to administration.
This is the correct answer. Reading medication labels at least two times before administration is
essential to ensure the right medication, dosage, route, and time. It is a crucial step in medication safety
protocols and helps prevent medication errors.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets
20 minutes ago.The client is lethargic and has a respiratory rate of 10/min.After securing the client's
airway and initiating an IV, which of the following actions should the nurse take next? A. Evaluate the
client for further suicidal behavior.
B. Administer flumazenil to the client.
C. Monitor the client's IV site for thrombophlebitis.
D. Initiate seizure precautions for the client. - answer-Initiate seizure precautions for the client.
This is the correct answer. Initiating seizure precautions is crucial in this situation because
benzodiazepine overdose can lead to seizures, especially during the recovery phase as the drug's effects
wear off. Implementing seizure precautions, such as padding the siderails and ensuring a safe
environment, helps prevent injury during a seizure episode.
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol.Which
of the following adverse effects should the nurse instruct the client to report to the provider? A.
Weight gain.
B. Dry mouth.
C. Shuffling gait.
D. Sedation. - answer-Shuffling gait.
This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with
the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a
shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it
may indicate the development of a serious neurological condition called tardive dyskinesia.
,A nurse is caring for an adolescent client who has cystic fibrosis.Which of the following actions should
the nurse instruct the client to take prior to initiating postural drainage? A. Eat a meal.
B. Take pancrelipase.
C. Use an albuterol inhaler.
D. Complete oral hygiene. - answer-Complete oral hygiene.
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.Which of the
following examples should the nurse include in the teaching as an example of malpractice? A.
Administering potassium via IV bolus.
B. Leaving a nasogastric tube clamped after administering oral medication.
C. Placing a yellow bracelet on a client who is at risk for falls.
D. Documenting communication with a provider in the progress notes of the client's medical record. -
answer-Administering potassium via IV bolus.
A nurse is performing a neurological examination on a client as part of a complete physical
assessment.The nurse should identify that cranial nerve XI is intact when the client performs which of
the following actions?
A. Sticks his tongue out.
B. Frowns symmetrically.
C. Identifies a sour taste.
D. Shrugs his shoulders. - answer-Shrugs his shoulders.
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open
system.Which of the following interventions should the nurse include in the plan of care? A. Maintain
bed elevation at 20 degrees.
B. Flush the tubing with 30 mL of water every 4 hr.
C. Check for gastric residual every 12 hr.
D. Place enough formula in the container to last 18 hr. - answer-Maintain bed elevation at 20 degrees.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the
therapeutic relationship.Which of the following statements should the nurse make during this phase?
, A. "We should establish our roles in the initial session."
B. "Let me show you simple relaxation exercises to manage stress."
C. "Let's talk about how you can change your response to stress."
D. "We should discuss resources to implement in your daily life." . - answer-"We should establish our
roles in the initial session."
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart
rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting
effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the
absence of distinct P waves on the ECG.
A nurse is assessing the fontanels of an 8-month-old infant.Which of the following findings should the
nurse recognize as an expected finding?
A. The anterior fontanel is open.
B. The posterior fontanel is open.
C. Both fontanels show molding.
D. Both fontanels are the same size. - answer-The anterior fontanel is open.
The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the
baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age.
It is a normal finding in an 8-month-old infant.
A nurse is planning care for a client who has acute appendicitis.Which of the following actions should the
nurse plan to take?
A. Administer a laxative to the client.
B. Keep the client on NPO status.
C. Place the client's head of bed flat.
D. Apply heat to the client's abdomen. - answer-Keep the client on NPO status.
