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Exam (elaborations)

ATI PN Comprehensive Exit – Assessment Technologies Institute (ATI) – 2026/2027

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ATI PN Comprehensive Exit – Assessment Technologies Institute (ATI) – 2026/2027

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ATI PN Comprehensive Exit – Assessment Technologies
Institute (ATI) – 2026/2027
SECTION I: SAFE AND EFFECTIVE CARE ENVIRONMENT
Questions 1–20


1. A nurse is caring for a client who is postoperative following a bowel resection.
Which of the following findings should the nurse report to the provider
immediately?
A. Urine output of 35 mL/hr
B. Serosanguineous wound drainage
C. Temperature of 38.1°C (100.6°F) on postoperative day 2
D. Sudden onset of chest pain and shortness of breath
E. Pain rated 5/10 at the incision site

Correct Answer: D. Sudden onset of chest pain and shortness of breath

Rationale: Sudden chest pain and shortness of breath in a postoperative
client indicates a possible pulmonary embolism, a life-threatening emergency
requiring immediate provider notification. All other findings are expected or
minor postoperative occurrences. Urine output of 35 mL/hr is acceptable
(minimum 30 mL/hr), serosanguineous drainage is normal, low-grade fever on day
2 is expected, and 5/10 pain is manageable.


2. A nurse is preparing to administer medications to four clients. Which client
should the nurse assess first?
A. A client with hypertension who has a blood pressure of 148/90 mmHg
B. A client with diabetes whose blood glucose is 180 mg/dL
C. A client with asthma who has a respiratory rate of 28/min and oxygen
saturation of 88%
D. A client with heart failure who has 1+ pitting edema in both ankles
E. A client with arthritis reporting pain of 6/10

, Correct Answer: C. A client with asthma who has a respiratory rate of
28/min and oxygen saturation of 88%

Rationale: Using the ABC priority framework, airway and breathing take
priority. An SpO₂ of 88% with tachypnea in an asthma client indicates respiratory
compromise requiring immediate intervention. The other findings are abnormal
but not immediately life-threatening.


3. A nurse is delegating tasks to an assistive personnel (AP). Which task is
appropriate to delegate?
A. Assessing a client's breath sounds
B. Teaching a client about a low-sodium diet
C. Measuring and recording urine output
D. Interpreting a client's pain level
E. Changing a sterile wound dressing

Correct Answer: C. Measuring and recording urine output

Rationale: Measuring and recording urine output is a routine, noninvasive
task within the scope of an AP. Assessment, teaching, interpretation, and sterile
procedures require nursing judgment and cannot be delegated.


4. A nurse is reviewing a client's medication list and notes the client takes
warfarin. Which statement by the client requires follow-up?
A. "I avoid eating large amounts of spinach."
B. "I take ibuprofen when I have a headache."
C. "I get my INR checked regularly."
D. "I wear a medical alert bracelet."
E. "I use an electric razor to shave."

Correct Answer: B. "I take ibuprofen when I have a headache."

Rationale: NSAIDs like ibuprofen increase the risk of bleeding when taken
with warfarin. The client should use acetaminophen instead and must be

,educated about this interaction. All other statements indicate appropriate
understanding of warfarin therapy.


5. A nurse is caring for a client in restraints. Which action is the nurse's priority?
A. Document the client's behavior every 8 hours
B. Remove the restraints every 2 hours for range-of-motion exercises
C. Ensure the restraints are tied to the bed frame
D. Obtain a new prescription every 48 hours
E. Assess skin integrity under the restraints every shift

Correct Answer: B. Remove the restraints every 2 hours for range-of-motion
exercises

Rationale: The priority is to prevent complications of immobility. Restraints
must be removed every 2 hours to allow for range-of-motion exercises, skin
assessment, and toileting. Documentation should be more frequent than every 8
hours, restraints should be tied to the bed frame (not side rails), prescriptions are
typically required every 24 hours (not 48), and skin assessment should occur more
frequently than every shift.


6. A nurse is preparing to insert a nasogastric tube for gastric decompression.
Which action should the nurse take first?
A. Measure the tube from the tip of the nose to the earlobe to the xiphoid
process
B. Place the client in a high-Fowler's position
C. Lubricate the tip of the tube with a water-soluble lubricant
D. Assess for bowel sounds
E. Auscultate for a whooshing sound over the epigastric area

Correct Answer: B. Place the client in a high-Fowler's position

Rationale: The priority action is to position the client in high-Fowler's position
to facilitate passage of the tube and reduce the risk of aspiration. Measuring the
tube, lubricating, and assessing bowel sounds are performed after positioning.

, 7. A nurse is caring for a client who has an indwelling urinary catheter. Which of
the following actions should the nurse take to prevent catheter-associated
urinary tract infection (CAUTI)?
A. Empty the urinary drainage bag every 12 hours
B. Keep the urinary drainage bag below the level of the bladder
C. Irrigate the catheter with sterile saline daily
D. Change the catheter every 48 hours
E. Place the drainage bag on the bed during transport

Correct Answer: B. Keep the urinary drainage bag below the level of the
bladder

Rationale: Keeping the drainage bag below the level of the bladder prevents
backflow of urine, which can introduce bacteria into the bladder. Emptying should
occur more frequently than every 12 hours, routine irrigation is not
recommended, and catheters should only be changed when clinically indicated.


8. A nurse is performing triage in an emergency department following a mass
casualty event. Which client should the nurse prioritize for immediate care?
A. A client with a minor laceration who is ambulatory
B. A client with a fractured femur who is alert and oriented
C. A client who is unresponsive with a palpable pulse
D. A client with a penetrating chest wound who is in respiratory distress
E. A client with a sprained ankle who is able to bear weight

Correct Answer: D. A client with a penetrating chest wound who is in
respiratory distress

Rationale: In mass casualty triage, clients with life-threatening but survivable
injuries (emergent/immediate category) receive priority. A penetrating chest
wound with respiratory distress requires immediate intervention. Unresponsive
clients with a pulse may have poor prognosis, while minor injuries can wait.

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