ATI PN COMPREHENSIVE FINAL EXAM
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: A nurse is caring for a client who spent the past
several minutes mumbling about being "doomed to die" and is now
pacing in an increasingly agitated and angry manner. Which of the
following actions should the nurse take first?
A. Administer PRN medication for agitation.
B. Attempt to reduce environmental stimuli.
C. Request a prescription for physical restraints.
D. Place the client in seclusion.
Answer:
Attempt to reduce environmental stimuli.
The nurse should apply the least restrictive priority-setting framework. This
framework assigns priority to nursing interventions that are least restrictive to the
client, as long as those interventions do not jeopardize the client's safety. Least
restrictive interventions promote the client's safety without using restraints. The
nurse should only use physical or chemical restraints when the safety of the client,
staff, or others is at risk. Therefore, the nurse should first attempt to calm the client
by decreasing environmental stimuli. The nurse should walk with the client to a quiet
area that places distance between him and other clients and from objects he could
use to hurt himself or others. The nurse should ensure that the area is visible to
other staff members in case more restrictive measures become necessary.
Question 2: A nurse on a pediatric mental health unit is caring for a
school-age child. Which of the following questions or statements
should the nurse make to foster rapport and engage him in
conversation?
Answer:
, "Tell me about your favorite video game."
Question 3: A community health nurse is planning care for four
high-risk newborns who were discharged yesterday. Which of the
following newborns should the nurse plan to care for first?
A. A 1-week-old newborn who needs another phenylketonuria
screening test
B. A 4-day-old newborn who has an elevated bilirubin level and
requires phototherapy
C. A 10-day-old newborn who is small for gestational age and who
requires daily weighing
D. A 2-week-old newborn who was born at 35 weeks of gestation and
weighed 2,268 g (5 lb) at discharge
Answer:
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy.
An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the
nurse to initiate phototherapy immediately to help prevent this dangerous outcome.
Question 4: A client comes to the emergency department in severe
respiratory distress following left-sided blunt chest trauma. The
nurse finds that the client has absent breath sounds on the left side
and a tracheal shift to the right. For which of the following
procedures should the nurse prepare the client?
Answer:
Chest tube insertion
Question 5: A nurse is teaching a client who has extensive deep
partial- ad full-thickness burns and requires a topical antimicrobial
,medication. The nurse should explain to the client that the goal of
this medication therapy is to reduce which of the following
outcomes?
A. Bacterial growth
B. Scarring
C. Skin graft size
D. Pain
Answer:
Bacterial growth
Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help
prevent bacteria from entering the body when a client has an impairment of the
protective covering of the skin, as with burns. It creates a protective barrier, along
with the dressing, between bacteria and the exposed body tissues. This therapy
helps prevent infection.
Question 6: A nurse is caring for a client who is taking warfarin.
Which of the following laboratory values should the nurse
recognize as an effective response to the medication?
Answer:
INR 3.0
Question 7: A nurse is caring for a client who is postoperative
following a laparotomy and has an indwelling urinary catheter and
a Jackson-Pratt drain in place. Which of the following findings
should indicate that the client is developing a postoperative
complication?
Answer:
Pulse oximetry of 85%
, Question 8: A nurse in the emergency department is caring for a
child who has bruises that the nurse suspects are d/t child abuse.
Which of the following actions should the nurse take?
Answer:
Report the suspected abuse to local authorities.
Question 9: A nurse is caring for a client who has chronic phantom
limb pain following an above-knee amputation. Which of the
following medication prescriptions should the nurse verify with the
provider?
Answer:
Meperidine.
Question 10: A nurse is caring for a client who has
pseudomembrane colitis d/t Clostridium difficile infection. Which of
the following interventions is the nurse's priority?
A. Performing hand hygiene before and after contact with the client
B. Reducing the client's anxiety due to isolation procedures.
C. Assisting the client in making nutritional choices
D. Monitoring the client's intake and output
Answer:
Performing hand hygiene before and after contact with the client.
C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two
virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and
produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying
cellular debris on the interior surface of the colon. The spores spread easily by
contact with body fluids and inanimate objects. The greatest risk to this client, as
well as to the nurse and others, is injury from infection transmission; therefore, the
priority intervention is hand hygiene.
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: A nurse is caring for a client who spent the past
several minutes mumbling about being "doomed to die" and is now
pacing in an increasingly agitated and angry manner. Which of the
following actions should the nurse take first?
A. Administer PRN medication for agitation.
B. Attempt to reduce environmental stimuli.
C. Request a prescription for physical restraints.
D. Place the client in seclusion.
Answer:
Attempt to reduce environmental stimuli.
The nurse should apply the least restrictive priority-setting framework. This
framework assigns priority to nursing interventions that are least restrictive to the
client, as long as those interventions do not jeopardize the client's safety. Least
restrictive interventions promote the client's safety without using restraints. The
nurse should only use physical or chemical restraints when the safety of the client,
staff, or others is at risk. Therefore, the nurse should first attempt to calm the client
by decreasing environmental stimuli. The nurse should walk with the client to a quiet
area that places distance between him and other clients and from objects he could
use to hurt himself or others. The nurse should ensure that the area is visible to
other staff members in case more restrictive measures become necessary.
Question 2: A nurse on a pediatric mental health unit is caring for a
school-age child. Which of the following questions or statements
should the nurse make to foster rapport and engage him in
conversation?
Answer:
, "Tell me about your favorite video game."
Question 3: A community health nurse is planning care for four
high-risk newborns who were discharged yesterday. Which of the
following newborns should the nurse plan to care for first?
A. A 1-week-old newborn who needs another phenylketonuria
screening test
B. A 4-day-old newborn who has an elevated bilirubin level and
requires phototherapy
C. A 10-day-old newborn who is small for gestational age and who
requires daily weighing
D. A 2-week-old newborn who was born at 35 weeks of gestation and
weighed 2,268 g (5 lb) at discharge
Answer:
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy.
An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the
nurse to initiate phototherapy immediately to help prevent this dangerous outcome.
Question 4: A client comes to the emergency department in severe
respiratory distress following left-sided blunt chest trauma. The
nurse finds that the client has absent breath sounds on the left side
and a tracheal shift to the right. For which of the following
procedures should the nurse prepare the client?
Answer:
Chest tube insertion
Question 5: A nurse is teaching a client who has extensive deep
partial- ad full-thickness burns and requires a topical antimicrobial
,medication. The nurse should explain to the client that the goal of
this medication therapy is to reduce which of the following
outcomes?
A. Bacterial growth
B. Scarring
C. Skin graft size
D. Pain
Answer:
Bacterial growth
Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help
prevent bacteria from entering the body when a client has an impairment of the
protective covering of the skin, as with burns. It creates a protective barrier, along
with the dressing, between bacteria and the exposed body tissues. This therapy
helps prevent infection.
Question 6: A nurse is caring for a client who is taking warfarin.
Which of the following laboratory values should the nurse
recognize as an effective response to the medication?
Answer:
INR 3.0
Question 7: A nurse is caring for a client who is postoperative
following a laparotomy and has an indwelling urinary catheter and
a Jackson-Pratt drain in place. Which of the following findings
should indicate that the client is developing a postoperative
complication?
Answer:
Pulse oximetry of 85%
, Question 8: A nurse in the emergency department is caring for a
child who has bruises that the nurse suspects are d/t child abuse.
Which of the following actions should the nurse take?
Answer:
Report the suspected abuse to local authorities.
Question 9: A nurse is caring for a client who has chronic phantom
limb pain following an above-knee amputation. Which of the
following medication prescriptions should the nurse verify with the
provider?
Answer:
Meperidine.
Question 10: A nurse is caring for a client who has
pseudomembrane colitis d/t Clostridium difficile infection. Which of
the following interventions is the nurse's priority?
A. Performing hand hygiene before and after contact with the client
B. Reducing the client's anxiety due to isolation procedures.
C. Assisting the client in making nutritional choices
D. Monitoring the client's intake and output
Answer:
Performing hand hygiene before and after contact with the client.
C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two
virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and
produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying
cellular debris on the interior surface of the colon. The spores spread easily by
contact with body fluids and inanimate objects. The greatest risk to this client, as
well as to the nurse and others, is injury from infection transmission; therefore, the
priority intervention is hand hygiene.
