ATI COMPREHENSIVE EXAM REVIEW B
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who has bipolar disorder and is experiencing acute
mania. The nurse obtained a verbal prescription for restraints. Which of the following
should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes - Answer-D. Document the client's
condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the
plan of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr - Answer-d. Administer
analgesics on a scheduled basis for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea - Answer-d. A client
who has a hip fracture and a new onset of tachypnea (NEW ONSET)
It is normal for pt to have weakness in lower extremities post Epidural analgesia
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse take?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to
promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client's skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply
immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together) - Answer-b. Wear gloves to apply the patch to the client's skin
A nurse has just received change-of-shift report for four clients. Which of the following
clients should the nurse assess first?
,a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hr
c. A client who has 100 mL fluid remaining in his IV bag
d. A client who received a pain medication 30 min ago for postoperative pain - Answer-
A. A client who was just given a glass of orange juice for a low blood glucose level
Patients B & C can wait
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler's position during the feeding
d. A residual of 65 mL 1hr postprandial - Answer-a. A history of gastroesophageal reflux
disease (GERD)
7. A nurse is reviewing the laboratory results for a client who has Cushing's disease.
The nurse should EXPECT the client to have an increase in which of the following
laboratory values?
a. Serum glucose level
b. Serum calcium level
c. Lymphocyte count
d. Serum potassium level - Answer-a. Serum glucose level- increased
b. Serum calcium level - decreased
c. Lymphocyte count - decreased immune system
d. Serum potassium level - decreased
Cushings disease is caused by
- The most common cause is the use of steroid drugs,
- also from a tumor or excess growth (hyperplasia) of the pituitary gland. The pituitary
gland is located just below the base of the brain. A type of pituitary tumor called an
adenoma is the other most common cause
Signs are a fatty hump between the shoulders, a rounded face, and pink or purple
stretch marks.
Treatment options include reducing steroid use, surgery, radiation, and medication.
8. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after
the client displaces toxicity. Which of the following actions should the nurse take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
,d. Administer calcium gluconate IV - Answer-D. Administer calcium gluconate IV
(antidote)
Always have an injectable form of calcium gluconate available when administering
magnesium sulfate by IV.
Why is magnesium sulfate given to pregnant women with preeclampsia? - Answer-
Magnesium sulfate can help prevent seizures in women with postpartum preeclampsia
who have severe signs and symptoms. Magnesium sulfate is typically taken for 24
hours. After treatment with magnesium sulfate, your health care provider will closely
monitor your blood pressure, urination and other symptoms
What is the antidote for magnesium sulfate (if mag toxicity occurs) - Answer-calcium
gluconate
S/S of mag sulfate toxicity
diarrhea.
nausea and vomiting.
lethargy.
muscle weakness.
abnormal electrical conduction in the heart.
low blood pressure.
urine retention.
respiratory distress.
9. A charge nurse is teaching new staff members about factors that increase a client's
risk to become violent. Which of the following risk factors should the nurse include as
the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison - Answer-C. Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders).
___________ is the presence of one or more additional conditions often co-occurring
with a primary condition - Answer-comorbidity
10. A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field
, d. Set up the sterile field 5 cm (2 in) below waist level - Answer-A. Place the cap from
the solution sterile side up on a clean surface ***
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the
body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5
cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;
should be ABOVE waist level
11. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime - Answer-A. Eat a light snack before bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who
lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess
first. - Answer-C. Identify environmental hazards in the home ** Assess first always
A, B, D are interventions
13. A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. "Can you tell me who visited you today?"
b. "What high school did you graduate from?"
c. "Can you list your current medications?"
d. "What did you have for breakfast yesterday?" - Answer-b. "What high school did you
graduate from?"
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who has bipolar disorder and is experiencing acute
mania. The nurse obtained a verbal prescription for restraints. Which of the following
should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes - Answer-D. Document the client's
condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the
plan of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr - Answer-d. Administer
analgesics on a scheduled basis for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea - Answer-d. A client
who has a hip fracture and a new onset of tachypnea (NEW ONSET)
It is normal for pt to have weakness in lower extremities post Epidural analgesia
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse take?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to
promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client's skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply
immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together) - Answer-b. Wear gloves to apply the patch to the client's skin
A nurse has just received change-of-shift report for four clients. Which of the following
clients should the nurse assess first?
,a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hr
c. A client who has 100 mL fluid remaining in his IV bag
d. A client who received a pain medication 30 min ago for postoperative pain - Answer-
A. A client who was just given a glass of orange juice for a low blood glucose level
Patients B & C can wait
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler's position during the feeding
d. A residual of 65 mL 1hr postprandial - Answer-a. A history of gastroesophageal reflux
disease (GERD)
7. A nurse is reviewing the laboratory results for a client who has Cushing's disease.
The nurse should EXPECT the client to have an increase in which of the following
laboratory values?
a. Serum glucose level
b. Serum calcium level
c. Lymphocyte count
d. Serum potassium level - Answer-a. Serum glucose level- increased
b. Serum calcium level - decreased
c. Lymphocyte count - decreased immune system
d. Serum potassium level - decreased
Cushings disease is caused by
- The most common cause is the use of steroid drugs,
- also from a tumor or excess growth (hyperplasia) of the pituitary gland. The pituitary
gland is located just below the base of the brain. A type of pituitary tumor called an
adenoma is the other most common cause
Signs are a fatty hump between the shoulders, a rounded face, and pink or purple
stretch marks.
Treatment options include reducing steroid use, surgery, radiation, and medication.
8. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after
the client displaces toxicity. Which of the following actions should the nurse take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
,d. Administer calcium gluconate IV - Answer-D. Administer calcium gluconate IV
(antidote)
Always have an injectable form of calcium gluconate available when administering
magnesium sulfate by IV.
Why is magnesium sulfate given to pregnant women with preeclampsia? - Answer-
Magnesium sulfate can help prevent seizures in women with postpartum preeclampsia
who have severe signs and symptoms. Magnesium sulfate is typically taken for 24
hours. After treatment with magnesium sulfate, your health care provider will closely
monitor your blood pressure, urination and other symptoms
What is the antidote for magnesium sulfate (if mag toxicity occurs) - Answer-calcium
gluconate
S/S of mag sulfate toxicity
diarrhea.
nausea and vomiting.
lethargy.
muscle weakness.
abnormal electrical conduction in the heart.
low blood pressure.
urine retention.
respiratory distress.
9. A charge nurse is teaching new staff members about factors that increase a client's
risk to become violent. Which of the following risk factors should the nurse include as
the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison - Answer-C. Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders).
___________ is the presence of one or more additional conditions often co-occurring
with a primary condition - Answer-comorbidity
10. A nurse is preparing to perform a sterile dressing change. Which of the following
actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field
, d. Set up the sterile field 5 cm (2 in) below waist level - Answer-A. Place the cap from
the solution sterile side up on a clean surface ***
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the
body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5
cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;
should be ABOVE waist level
11. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime - Answer-A. Eat a light snack before bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who
lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess
first. - Answer-C. Identify environmental hazards in the home ** Assess first always
A, B, D are interventions
13. A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. "Can you tell me who visited you today?"
b. "What high school did you graduate from?"
c. "Can you list your current medications?"
d. "What did you have for breakfast yesterday?" - Answer-b. "What high school did you
graduate from?"
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast
