ATI Comprehensive Exam 2021 (All questions and answers)

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ATI COMPREHENSIVE C 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 client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes mellitus and a hemoglobin A1C of 6.8% A client who has epidural analgesia and weakness in the lower extremities A client who has a hip fracture and a new onset of tachypnea Request a renewal of the prescription every 8 hr. Check the client’s peripheral pulse rate every 30 min Obtain a prescription for restraint within 4 hr. Document the client’s condition every 15 minutes A nursing planning care for a school-age child who is 4 hr postoperative following Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) Give cromolyn nebulizer solution every 6 hr (for asthma) Administer analgesics on a scheduled basis for the first 24 hr 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? Apply a warm compress to the operative site every 4 hr 4following actions should the nurse tak e? a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid oily or broken skin) A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the b. Wear gloves to apply the patch to the client’s skin c. d. pressed together) 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? Apply the patch within 1 hr of removing it from the protective pouch (apply immediately) Remove the previous patch and place it in a tissue (fold patch in half with sticky sides 40. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? P. 482 ch 75 CONFIRMED 1. Providing pain management 2. Offering emotional support 3. Preventing infection 41. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. D. Tell her not to worry. She still has plenty of time left. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? d. Initiating IV fluid resuscitation - they are at risk for hypovolemic shock d/t 3rd spacing 2. Let's talk about your mom’s cancer and how things will progress from here. 3. Tell me how you are feeling about your mom dying. E. You sound like you have questions about your mom dying. Let’s talk about it. Rationale: Therapeutic communication 42. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. A client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) 43. A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? 1. Clarify the source of the referral 2. Implement the nursing process 3. Schedule a time for the home visit 4. Contact the family by phone ! 44. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? 1. You have the right to decide who receives information - 2. Your partner can be a great source of support for you at this time 3. Is there a reason you don’t want your partner to know about your procedure? 4. The provider will be tactful when talking to your partner 45. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? 1. 7.5% 2. 15% 3. 8.1% 4. 13.3% 46. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? 1. Perform fundal massage ( massage if fundus is boggy) 2. Pour water from a squeeze bottle over the client’s perineal area. 3. Insert an indwelling urinary catheter. 4. Apply cold therapy to the client’s perineal area.( warm) 47. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? 1. Avoid hot tub while wearing the patch 2. Apply patch to your forearm 3. Avoid high-fiber foods while taking this medication 4. Remove the patch for 8 hours every day to reduce the risk for tolerance. 48. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan? 2. Place the client upright on a donut-shaped cushion 3. Assess pressure points every 24 hr.- must assess 4. Turn and reposition the client every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. 49. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? 1. We should discuss resources to implement in your daily life 2. Let me show you simple relaxation exercises to manage stress. 3. Let’s talk about how you can change your response to stress 4. We should establish our roles in the initial session. 50. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? 1. Avocados 2. Whole grain bread 3. Pepperoni pizza 4. Smoked salmon ????? 51. A nurse enters a client’s room and sees a small fire in the client’s bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps) a. Transport the client to another area of the nursing unit (1) b. Activate the facility’s fire alarm system (2) c. Close all nearby windows and doors (3) d. Use the unit’s fire extinguisher to attempt to put out the fire (4) 52. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? 1. Heightened perceptual field 2. Rapid speech -severe 3. Feelings of dread 4. Purposeless activity 53. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) 1. Tremors 2. Polydipsia = hyperglycemia 3. Acetone Breath odor = DKA a. Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic) 4. Diaphoresis 5. Inability to concentrate 54. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? 1. Upper extremity hypotension 2. Increased intracranial pressure 3. Frequent nosebleeds 4. Weak femoral pulses 55. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) 2. Locate financial support to open a shelter for abuse survivors (3rd) 3. Teach parenting skills to families at risk for abuse 4. Connect abuse survivors with legal counsel (3rd) 56. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? 1. Documenting the report of pain for a client who is postoperative 2. Administering oral fluids to a client who has dysphagia- 3. Applying a condom catheter for a client who has a spinal cord injury 4. Reviewing active range-of-motion exercise with a client who had a stroke 57. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? 1. “I will take sucralfate with meals three times per day” 2. “I will avoid food and beverages that contain caffeine” 3. “I will decrease my daily protein intake to 15 grams per day” 4. “I will use ibuprofen as needed to control abdominal pain” 58. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? 1. Offer the client saltine crackers between meals 2. Suggest rinsing his mouth with an alcohol-based mouthwash 3. Provide humidification of the room air 4. Instruct the client on the use of esophageal speech 59. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication- b. Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputee- d. Apply a transdermal nicotine patch- *60. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? 1. The client takes vitamin C daily 2. The client has a history of alcohol use disorder 3. The client has a history of asthma 4. The client takes furosemide twice daily 61. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? 1. Increased salivation- dry it will cause - anticholinergic effects 2. Weight loss 3. Urinary retention- 4. Hypertension- orthostatic hypotension it will cause instead [Show More]

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