ATI COMPREHENSIVE EXIT EXAM PRACTICE
QUESTIONS AND 100% VERIFIED ANSWERS
AND DETAILED RATIONALE
1) SCENARIO (Postoperative Care)
A nurse is caring for a client who is 24 hours postoperative following an
abdominal hysterectomy. Which of the following assessment findings
requires immediate intervention?
A. Heart rate 88/min
B. Respiratory rate 18/min
C. Wound edges approximated with serosanguineous drainage
D. Urinary output of 20 mL/hr
Correct Answer: D. Urinary output of 20 mL/hr
Rationale: Urinary output below 30 mL/hr indicates inadequate renal
perfusion and requires immediate intervention. The other findings are
within expected postoperative parameters.
2) SCENARIO (Medication Administration)
A nurse is preparing to administer digoxin to a client with heart failure.
Which of the following findings indicates the medication should be
withheld?
,A. Blood pressure 110/70 mmHg
B. Apical pulse 52/min
C. Respiratory rate 16/min
D. Serum potassium 4.0 mEq/L
Correct Answer: B. Apical pulse 52/min
Rationale: Digoxin should be withheld if the apical pulse is below
60/min in adults. A pulse of 52/min is bradycardic and indicates digoxin
toxicity or excessive therapeutic effect. The nurse should notify the
provider.
3) SCENARIO (Maternity - Preeclampsia)
A nurse is assessing a client at 36 weeks gestation who has
preeclampsia. Which of the following findings should the nurse report
to the provider?
A. Blood pressure 142/90 mmHg
B. 1+ protein in urine
C. Epigastric pain
D. Slight edema of the lower extremities
Correct Answer: C. Epigastric pain
Rationale: Epigastric pain in a client with preeclampsia is a sign of
impending eclampsia and liver involvement (HELLP syndrome). This
requires immediate notification of the provider.
4) SCENARIO (Mental Health - Depression)
A nurse is caring for a client with major depressive disorder who has
,been prescribed fluoxetine. Which of the following adverse effects
should the nurse include in client teaching?
A. Weight gain
B. Hypertensive crisis
C. Sexual dysfunction
D. Sedation
Correct Answer: C. Sexual dysfunction
Rationale: SSRIs like fluoxetine commonly cause sexual dysfunction
including decreased libido and anorgasmia. Weight loss (not gain) is
more common initially, and sedation is less common with fluoxetine
than some other antidepressants.
5) SCENARIO (Infection Control)
A nurse is caring for a client diagnosed with Clostridium difficile. Which
of the following infection control precautions should the nurse
implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Correct Answer: C. Contact precautions
Rationale: C. difficile is transmitted via the fecal-oral route and requires
contact precautions. The nurse should use gloves and a gown when
entering the room and perform hand hygiene with soap and water (not
alcohol-based hand sanitizer).
, 6) SCENARIO (Pediatric - Immunizations)
A nurse is providing teaching to the parents of a 2-month-old infant
about immunizations. Which of the following vaccines should the nurse
administer at this visit?
A. MMR
B. Varicella
C. DTaP
D. Hepatitis A
Correct Answer: C. DTaP
Rationale: At 2 months of age, the infant should receive DTaP, IPV, Hib,
PCV, and RV. MMR and varicella are administered at 12-15 months.
Hepatitis A is given at 12-23 months.
7) SCENARIO (IV Therapy)
A nurse is caring for a client receiving a blood transfusion. The client
develops chills, fever, and flank pain. Which of the following actions
should the nurse take first?
A. Stop the transfusion
B. Notify the provider
C. Administer antihistamines
D. Obtain a urine sample
Correct Answer: A. Stop the transfusion
QUESTIONS AND 100% VERIFIED ANSWERS
AND DETAILED RATIONALE
1) SCENARIO (Postoperative Care)
A nurse is caring for a client who is 24 hours postoperative following an
abdominal hysterectomy. Which of the following assessment findings
requires immediate intervention?
A. Heart rate 88/min
B. Respiratory rate 18/min
C. Wound edges approximated with serosanguineous drainage
D. Urinary output of 20 mL/hr
Correct Answer: D. Urinary output of 20 mL/hr
Rationale: Urinary output below 30 mL/hr indicates inadequate renal
perfusion and requires immediate intervention. The other findings are
within expected postoperative parameters.
2) SCENARIO (Medication Administration)
A nurse is preparing to administer digoxin to a client with heart failure.
Which of the following findings indicates the medication should be
withheld?
,A. Blood pressure 110/70 mmHg
B. Apical pulse 52/min
C. Respiratory rate 16/min
D. Serum potassium 4.0 mEq/L
Correct Answer: B. Apical pulse 52/min
Rationale: Digoxin should be withheld if the apical pulse is below
60/min in adults. A pulse of 52/min is bradycardic and indicates digoxin
toxicity or excessive therapeutic effect. The nurse should notify the
provider.
3) SCENARIO (Maternity - Preeclampsia)
A nurse is assessing a client at 36 weeks gestation who has
preeclampsia. Which of the following findings should the nurse report
to the provider?
A. Blood pressure 142/90 mmHg
B. 1+ protein in urine
C. Epigastric pain
D. Slight edema of the lower extremities
Correct Answer: C. Epigastric pain
Rationale: Epigastric pain in a client with preeclampsia is a sign of
impending eclampsia and liver involvement (HELLP syndrome). This
requires immediate notification of the provider.
4) SCENARIO (Mental Health - Depression)
A nurse is caring for a client with major depressive disorder who has
,been prescribed fluoxetine. Which of the following adverse effects
should the nurse include in client teaching?
A. Weight gain
B. Hypertensive crisis
C. Sexual dysfunction
D. Sedation
Correct Answer: C. Sexual dysfunction
Rationale: SSRIs like fluoxetine commonly cause sexual dysfunction
including decreased libido and anorgasmia. Weight loss (not gain) is
more common initially, and sedation is less common with fluoxetine
than some other antidepressants.
5) SCENARIO (Infection Control)
A nurse is caring for a client diagnosed with Clostridium difficile. Which
of the following infection control precautions should the nurse
implement?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Correct Answer: C. Contact precautions
Rationale: C. difficile is transmitted via the fecal-oral route and requires
contact precautions. The nurse should use gloves and a gown when
entering the room and perform hand hygiene with soap and water (not
alcohol-based hand sanitizer).
, 6) SCENARIO (Pediatric - Immunizations)
A nurse is providing teaching to the parents of a 2-month-old infant
about immunizations. Which of the following vaccines should the nurse
administer at this visit?
A. MMR
B. Varicella
C. DTaP
D. Hepatitis A
Correct Answer: C. DTaP
Rationale: At 2 months of age, the infant should receive DTaP, IPV, Hib,
PCV, and RV. MMR and varicella are administered at 12-15 months.
Hepatitis A is given at 12-23 months.
7) SCENARIO (IV Therapy)
A nurse is caring for a client receiving a blood transfusion. The client
develops chills, fever, and flank pain. Which of the following actions
should the nurse take first?
A. Stop the transfusion
B. Notify the provider
C. Administer antihistamines
D. Obtain a urine sample
Correct Answer: A. Stop the transfusion
