ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
You’re in a code doing CPR, check
LOC, then do your ABC (airway,
wrong answers always share something
similar. Chose what is unique and
different. DO NOT USE THIS UNLESS
LAST RESORT
With the exception- If there is a scene of an UNwitnessed accident, if someone is pulseless or breathless,
they are of low priority.
Who is healthiest who is sickest Disaster in town, if you have to discharge someone, who do you discharge-
lowest priority client Received report on 4 patients, which will you check first- highest
While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube
becomes dislodged from the chest wall. What is the nurse's priority action?
While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the
client coughs and expels the endotracheal tube. What is the priority nursing action?
Which is highest priority in caring
for a suicidal patient? (One pt)
1. When you’re stuck between two
answers, reread the question.
When traveling by automobile, newborns and children age <2 must be placed in a rear-facing car seat in the back seat. The
car seat's harness should be secured snugly at or below the shoulders, at the hips, and between the legs; parents should avoid
using blankets, bulky coats, or sleep sacks between the newborn and the harness.
When the nurse provides education about starting risperidone, which statement by the client's caregiver indicates a need for
further teaching?
When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is
immunocompromised in a room with a client who has an active or suspected infection.
When making room assignments, it is important to remember that a client with an active or suspected infection should not
be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection
surgery (Option 3).
1. When in doubt, call it normal.
(Ex. Some 6 yo can read and some
can’t. Give it more time.)
2. When in doubt pick the older age
when you narrow it down (ex. 12 and
14 months, pick 14mo, give them more
time)
3. When in doubt pick the easier
When caring for clients in skeletal traction, the nurse should encourage increased fluid intake, ensure that pulley weights
hang freely, inspect pin sites for signs of infection, and perform frequent neurovascular checks on the affected extremity.
When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse to delegate to
the licensed practical nurse? Select all that apply.
When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and
remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment
needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that
the client can carry and eat without having to sit down (Option 3).
When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others on the health care
team. Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the
professional boundary.
• Weight loss because excessive abdominal fat may increase gastric pressure
• Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4)
Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and
1
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
children age <2 years must be placed in a rear-facing car seat in the vehicle's back seat. The car seat's harness is secured
snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest.
varies in length, balloon should not be inflated until catheter is fully advanced.
• Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between
voiding (Option 5)
1. Use the nondominant hand to grasp the cuff of the dominant glove. Touch only the inside surface of the
glove (Option 6).
1. Use of the word unstable
1. Use of the word stable
• Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5)
• Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution
using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).
Urosepsis is a type of bloodstream infection that originates from the urinary tract. The initial treatment of sepsis focuses on
the management or prevention of septic shock, mainly by administering boluses of isotonic IV fluids (fluid resuscitation)
Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a
strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological
system dysfunction (eg, Parkinson disease, stroke) or spinal cord injury. Interventions for clients with UI include:
Urge incontinence (UI) involves random bladder contractions that cause a strong, sudden urge to urinate followed by urine
leakage. Interventions for UI include losing excess weight, avoiding dietary bladder irritants, performing pelvic floor
exercises, taking anticholinergic medications, and using bladder training techniques.
1. Unstable beats stable (unstable is highest priority) Words that make you stable-
2. Unchanged assessments
Ulcerative colitis (UC) is a chronic disease characterized by inflammation and ulcerations in the large intestines, resulting in
urgent, frequent, bloody diarrhea; abdominal pain; fever; and fatigue.
UAPS can do-
UAP = unlicensed assistive personnel.
Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure.
The skin is assessed at the bleb administration site 48-72 hours after placement. Positive results include an induration of ≥15
mm in healthy individuals, ≥5 mm in high-risk populations and ≥10 mm in clients with potential risk or mild
immunosuppression. Redness without induration is a negative reaction.
Tricuspid 4th intercostal space at the left sternal border
Mitral/Apical 5th intercostal space at the mid clavicle line
HOW TO GUESS-
TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes
simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health
care workers.
Toddlers- always chose finger foods (what they can eat on the run)
To reduce the risk for drug interactions, the nurse should encourage clients to bring all medications (ie, prescription, over-the-
counter, herbal supplements) to each appointment.
To maintain patency of a continuous bladder irrigation system, the registered nurse (RN) must monitor the quality of
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile
fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using
dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.
tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100%
oxygen until reintubation is achieved (Option 2).
Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism.
TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles.
this time is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine
to alleviate uncontrolled pain (Option 3).
This immigrant client has a positive purified protein derivative test (>10-mm induration). The bacille Calmette-Guérin
vaccine improves TB resistance in high-risk countries but produces false-positive tuberculin skin test results. Knowing this
information and documenting it is important (Options 1 and 2).
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is
treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health
2
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg,
myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight <99.2 lb [45 kg]).
There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage
victims. Which client should the nurse send to the hospital first?
2. The umbrella strategy- which
answer is more global? An answer
that covers all the overs without
The therapeutic nurse-client relationship focuses on client needs and has clear, well-defined professional boundaries.
Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the
professional boundary. When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others
on the health care team (Option 1). The client can then decide whether or not to disclose the information.
The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of
depression. Which statement by the student indicates a need for further teaching?
The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly
requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of
morphine." Which action by the charge nurse is the priority at this time?
3. The Sesame Street rule: use when
and only when you have no other
option when nothing else works.
Right answers tend to be different
than the other answers because it’s
the only one that is right. The
The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with
illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's
The registered nurse cannot delegate tasks requiring clinical judgment, such as initial teaching and parts of the nursing
process, including assessment, planning, and evaluation. Licensed practical nurses can monitor assessment findings,
administer medications via most routes, and reinforce teaching.
The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel
(UAP):
The priorities of care for suspected placental abruption include close monitoring of the client (hemodynamic status) and fetus
(continuous fetal heart rate monitoring). Additional interventions may include initiation of a large-bore IV line,
administration of fluids and blood products, and possible emergency cesarean birth.
The primary nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the primary nurse
requires the charge nurse to intervene?
The primary goal of the first prenatal visit is to establish rapport and emphasize the importance of consistent prenatal
3. The phrases “ready for discharge” “to be discharged” “admitted longer than 24 hrs ago”
2. The phrases “Not ready for discharge” “newly admitted” “newly diagnosed” “admitted less than 24 hours
ago”
The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition
presents the most concern as a safety hazard in the child's home environment?
The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses
breach client confidentiality? Select all that apply.
The nurse will examine their own feelings about something
The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines,
morphine, oxygen, nitroglycerin, aspirin) for the client with acute chest pain. Upright positioning improves ventilation and
reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers),
and place the client on continuous cardiac monitoring.
The nurse should monitor clients in physical restraints according to governmental and regulatory agency guidelines and
facility policy. Guidelines include regularly assessing neurovascular status; releasing restraints for skin assessment and range
of motion exercises; and offering fluids, nutrition, and toileting.
The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory
3
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
reporting. Signs of abuse may include:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of
healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to
state or provincial laws.
The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements
about self-management strategies indicate that teaching has been effective? Select all that apply.
The nurse receives report on 4 clients. Which client should the nurse see first?
The nurse receives handoff of care report on four clients. Which client should the nurse assess first?
The nurse promotes client safety by implementing fall risk precautions. A client with multiple fall risk factors has an
increased risk for falls and requires additional precautions (eg, bed alarm, room close to nurses' station, bedside commode
close to bed).
The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the
appropriate nursing interventions related to administration of this medication? Select all that apply.
The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial
infarction. What action should the nurse take first? Click on the exhibit button for additional information.
The nurse needs to quickly identify the signs and symptoms of myocardial infarction (eg, chest pain, diaphoresis, dyspnea,
anxiety) and initiate interventions to preserve cardiac muscle. The nurse also recognizes that female and older clients may
have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). The following are initial interventions in the
emergency management of chest pain:
The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a
pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not
breathing and is now pale with a pulse of 49/min. What is the nurse's next action?
The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate
understanding of the teaching? Select all that apply.
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse
identifies which finding as most likely to hinder healing?
The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary
disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider?
The nurse is reviewing client phone messages. Which client should the nurse call back first?
The nurse is responsible for protecting client confidentiality and preventing inappropriate sharing of protected health
information (PHI). Sharing a client's PHI on social media breaches confidentiality, even if the client's name is not identified
or sharing is in a private message.
The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and
mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following statements by the
client indicate appropriate understanding of teaching? Select all that apply.
The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux
disease. Which of the following statements by the client indicate a correct understanding? Select all that apply.
The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which
information would be a priority for the nurse to include?
The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile
gloves in the correct order. All options must be used.
The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is
the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for
more information. Record your answer using a whole number.
The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the
available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the
nurse program the infusion pump? Record the answer using a whole number.
The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after
attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan?
4
You’re in a code doing CPR, check
LOC, then do your ABC (airway,
wrong answers always share something
similar. Chose what is unique and
different. DO NOT USE THIS UNLESS
LAST RESORT
With the exception- If there is a scene of an UNwitnessed accident, if someone is pulseless or breathless,
they are of low priority.
Who is healthiest who is sickest Disaster in town, if you have to discharge someone, who do you discharge-
lowest priority client Received report on 4 patients, which will you check first- highest
While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube
becomes dislodged from the chest wall. What is the nurse's priority action?
While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the
client coughs and expels the endotracheal tube. What is the priority nursing action?
Which is highest priority in caring
for a suicidal patient? (One pt)
1. When you’re stuck between two
answers, reread the question.
When traveling by automobile, newborns and children age <2 must be placed in a rear-facing car seat in the back seat. The
car seat's harness should be secured snugly at or below the shoulders, at the hips, and between the legs; parents should avoid
using blankets, bulky coats, or sleep sacks between the newborn and the harness.
When the nurse provides education about starting risperidone, which statement by the client's caregiver indicates a need for
further teaching?
When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is
immunocompromised in a room with a client who has an active or suspected infection.
When making room assignments, it is important to remember that a client with an active or suspected infection should not
be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma
exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection
surgery (Option 3).
1. When in doubt, call it normal.
(Ex. Some 6 yo can read and some
can’t. Give it more time.)
2. When in doubt pick the older age
when you narrow it down (ex. 12 and
14 months, pick 14mo, give them more
time)
3. When in doubt pick the easier
When caring for clients in skeletal traction, the nurse should encourage increased fluid intake, ensure that pulley weights
hang freely, inspect pin sites for signs of infection, and perform frequent neurovascular checks on the affected extremity.
When caring for a client with ulcerative colitis, which nursing activities are appropriate for the registered nurse to delegate to
the licensed practical nurse? Select all that apply.
When caring for a client with signs of a central line–related bloodstream infection, the nurse should obtain blood cultures and
remove the device, if possible, before beginning antibiotic therapy. Other nursing interventions (eg, symptom management,
documentation) should be done after initiating treatment of the infection.
When caring for a client with mania, the nurse should prioritize physiological needs over psychological or self-fulfillment
needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that
the client can carry and eat without having to sit down (Option 3).
When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others on the health care
team. Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the
professional boundary.
• Weight loss because excessive abdominal fat may increase gastric pressure
• Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4)
Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and
1
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
children age <2 years must be placed in a rear-facing car seat in the vehicle's back seat. The car seat's harness is secured
snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest.
varies in length, balloon should not be inflated until catheter is fully advanced.
• Using bladder training, such as voiding every 2 hours while awake and gradually lengthening the intervals between
voiding (Option 5)
1. Use the nondominant hand to grasp the cuff of the dominant glove. Touch only the inside surface of the
glove (Option 6).
1. Use of the word unstable
1. Use of the word stable
• Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5)
• Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5).
• Use dominant (sterile) hand to cleanse in a circular motion from the meatus to the glans with antiseptic solution
using cotton balls or swab sticks. Use new cotton ball/swab stick with each swipe (Option 4).
Urosepsis is a type of bloodstream infection that originates from the urinary tract. The initial treatment of sepsis focuses on
the management or prevention of septic shock, mainly by administering boluses of isotonic IV fluids (fluid resuscitation)
Urge incontinence (UI), also known as overactive bladder, occurs when the bladder contracts randomly, causing a
strong, sudden urge to urinate followed by urine leakage. UI may occur without cause or may result from neurological
system dysfunction (eg, Parkinson disease, stroke) or spinal cord injury. Interventions for clients with UI include:
Urge incontinence (UI) involves random bladder contractions that cause a strong, sudden urge to urinate followed by urine
leakage. Interventions for UI include losing excess weight, avoiding dietary bladder irritants, performing pelvic floor
exercises, taking anticholinergic medications, and using bladder training techniques.
1. Unstable beats stable (unstable is highest priority) Words that make you stable-
2. Unchanged assessments
Ulcerative colitis (UC) is a chronic disease characterized by inflammation and ulcerations in the large intestines, resulting in
urgent, frequent, bloody diarrhea; abdominal pain; fever; and fatigue.
UAPS can do-
UAP = unlicensed assistive personnel.
Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure.
The skin is assessed at the bleb administration site 48-72 hours after placement. Positive results include an induration of ≥15
mm in healthy individuals, ≥5 mm in high-risk populations and ≥10 mm in clients with potential risk or mild
immunosuppression. Redness without induration is a negative reaction.
Tricuspid 4th intercostal space at the left sternal border
Mitral/Apical 5th intercostal space at the mid clavicle line
HOW TO GUESS-
TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes
simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health
care workers.
Toddlers- always chose finger foods (what they can eat on the run)
To reduce the risk for drug interactions, the nurse should encourage clients to bring all medications (ie, prescription, over-the-
counter, herbal supplements) to each appointment.
To maintain patency of a continuous bladder irrigation system, the registered nurse (RN) must monitor the quality of
To insert an indwelling urinary catheter in a male client, perform hand hygiene, apply sterile gloves and place sterile
fenestrated drape, arrange supplies on sterile field, grasp penis with nondominant hand, cleanse from meatus to glans using
dominant hand, insert catheter until urine return is visualized, advance catheter to tubing bifurcation, and inflate balloon.
tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100%
oxygen until reintubation is achieved (Option 2).
Thromboembolic deterrent stockings (TED hose) promote venous return and reduce the risk of venous thromboembolism.
TED hose are worn continually and should be properly sized, free of folds, rolls, or wrinkles.
this time is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine
to alleviate uncontrolled pain (Option 3).
This immigrant client has a positive purified protein derivative test (>10-mm induration). The bacille Calmette-Guérin
vaccine improves TB resistance in high-risk countries but produces false-positive tuberculin skin test results. Knowing this
information and documenting it is important (Options 1 and 2).
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is
treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health
2
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg,
myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L],
anuric, weight <99.2 lb [45 kg]).
There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage
victims. Which client should the nurse send to the hospital first?
2. The umbrella strategy- which
answer is more global? An answer
that covers all the overs without
The therapeutic nurse-client relationship focuses on client needs and has clear, well-defined professional boundaries.
Keeping a client's secrets is a sign of countertransference (eg, overinvolvement with the client) and a violation of the
professional boundary. When asked to keep a secret, the nurse must be honest and state that it may be necessary to tell others
on the health care team (Option 1). The client can then decide whether or not to disclose the information.
The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of
depression. Which statement by the student indicates a need for further teaching?
The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly
requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of
morphine." Which action by the charge nurse is the priority at this time?
3. The Sesame Street rule: use when
and only when you have no other
option when nothing else works.
Right answers tend to be different
than the other answers because it’s
the only one that is right. The
The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with
illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's
The registered nurse cannot delegate tasks requiring clinical judgment, such as initial teaching and parts of the nursing
process, including assessment, planning, and evaluation. Licensed practical nurses can monitor assessment findings,
administer medications via most routes, and reinforce teaching.
The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel
(UAP):
The priorities of care for suspected placental abruption include close monitoring of the client (hemodynamic status) and fetus
(continuous fetal heart rate monitoring). Additional interventions may include initiation of a large-bore IV line,
administration of fluids and blood products, and possible emergency cesarean birth.
The primary nurse is preparing a client with atrial fibrillation for scheduled cardioversion. What action by the primary nurse
requires the charge nurse to intervene?
The primary goal of the first prenatal visit is to establish rapport and emphasize the importance of consistent prenatal
3. The phrases “ready for discharge” “to be discharged” “admitted longer than 24 hrs ago”
2. The phrases “Not ready for discharge” “newly admitted” “newly diagnosed” “admitted less than 24 hours
ago”
The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition
presents the most concern as a safety hazard in the child's home environment?
The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses
breach client confidentiality? Select all that apply.
The nurse will examine their own feelings about something
The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV lines,
morphine, oxygen, nitroglycerin, aspirin) for the client with acute chest pain. Upright positioning improves ventilation and
reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray, and blood work (eg, cardiac markers),
and place the client on continuous cardiac monitoring.
The nurse should monitor clients in physical restraints according to governmental and regulatory agency guidelines and
facility policy. Guidelines include regularly assessing neurovascular status; releasing restraints for skin assessment and range
of motion exercises; and offering fluids, nutrition, and toileting.
The nurse should be aware of signs of physical, sexual, and emotional abuse and comply with state or provincial mandatory
3
, ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE
reporting. Signs of abuse may include:
The nurse should be aware of signs of physical, sexual, and emotional abuse, including repeated injuries in varied stages of
healing, shaken baby syndrome, and injuries to genitalia. Suspicion of abuse necessitates mandatory reporting according to
state or provincial laws.
The nurse reinforces teaching to a client recently diagnosed with urge incontinence. Which of the following client statements
about self-management strategies indicate that teaching has been effective? Select all that apply.
The nurse receives report on 4 clients. Which client should the nurse see first?
The nurse receives handoff of care report on four clients. Which client should the nurse assess first?
The nurse promotes client safety by implementing fall risk precautions. A client with multiple fall risk factors has an
increased risk for falls and requires additional precautions (eg, bed alarm, room close to nurses' station, bedside commode
close to bed).
The nurse prepares to administer potassium chloride to a client through a peripherally inserted IV line. What are the
appropriate nursing interventions related to administration of this medication? Select all that apply.
The nurse on the cardiac unit reviews a current rhythm strip from a client who experienced an inferior wall myocardial
infarction. What action should the nurse take first? Click on the exhibit button for additional information.
The nurse needs to quickly identify the signs and symptoms of myocardial infarction (eg, chest pain, diaphoresis, dyspnea,
anxiety) and initiate interventions to preserve cardiac muscle. The nurse also recognizes that female and older clients may
have nonspecific symptoms (eg, fatigue, indigestion, shortness of breath). The following are initial interventions in the
emergency management of chest pain:
The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a
pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not
breathing and is now pale with a pulse of 49/min. What is the nurse's next action?
The nurse is teaching about constipation prevention to a client. Which of the following client statements indicate appropriate
understanding of the teaching? Select all that apply.
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse
identifies which finding as most likely to hinder healing?
The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary
disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider?
The nurse is reviewing client phone messages. Which client should the nurse call back first?
The nurse is responsible for protecting client confidentiality and preventing inappropriate sharing of protected health
information (PHI). Sharing a client's PHI on social media breaches confidentiality, even if the client's name is not identified
or sharing is in a private message.
The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and
mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following statements by the
client indicate appropriate understanding of teaching? Select all that apply.
The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux
disease. Which of the following statements by the client indicate a correct understanding? Select all that apply.
The nurse is preparing to teach a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which
information would be a priority for the nurse to include?
The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile
gloves in the correct order. All options must be used.
The nurse is preparing to administer acetaminophen to a 4-year-old client weighing 43 lb. Based on the prescription, what is
the volume of medication in milliliters (mL) that the child should receive with each dose? Click on the exhibit button for
more information. Record your answer using a whole number.
The nurse is preparing to administer a continuous dopamine infusion at 5 mcg/kg/min. The client weighs 187 lb and the
available medication contains 400 mg of dopamine in 250 mL of D5W. At what rate in milliliters per hour (mL/hr) should the
nurse program the infusion pump? Record the answer using a whole number.
The nurse is planning care for a client with bipolar disorder and acute mania who is being admitted involuntarily after
attempting to run across a five-lane highway. Which intervention is the priority to include in the care plan?
4
