ATI Comprehensive Exit Exam: 180 Questions & Answers

Informed Consent for ECT

A client has the right to withdraw consent for the treatment at any time.

Fraying on Electrical Cord

The nurse should first remove the device from the room.

Hydromorphone Prescription

The nurse should count the current number of unit doses available in the medication dispensing system.

Priority Finding Post Cast Placement

A client 2 hours post cast placement with 2+ pitting edema and pallor has the priority finding.

Disulfiram Alcohol Use

A client should limit alcohol use to one drink daily while taking disulfiram.

Fluoxetine and Tyramine

A client should avoid foods containing tyramine while taking fluoxetine.

Sustained-Release Methylphenidate

A client should take the sustained-release methylphenidate every morning.

Major Depressive Disorder Precautions

The nurse should implement seizure precautions for the client.

Narcissistic Personality Disorder Expectation

The nurse should expect the client to be preoccupied with aging.

Time Management in Nursing

The nurse should first determine goals of the day.

Change-of-Shift Assessment Priority

The priority finding is a client with pneumonia, productive cough, and fever of 38.8° C (101.8° F).

Medication Administration Documentation

The nurse should document administration of the medication upon removal from the medication dispensing system.

Withholding Medication

The nurse should withhold hydromorphone if the client does not appear to be in pain.

Client Teaching in Mental Health

Understanding is indicated when a client states they will take their lithium on an empty stomach.

Seizure Precautions

Implementing seizure precautions is a priority action for a client with major depressive disorder.

Client Assessment in Mental Health

Encouraging the client to verbalize feelings is an important action but not the first priority.

Electrical Device Safety

Reporting the defect to the equipment maintenance staff is necessary but should follow immediate removal of the device.

Medication Dispensing System

The nurse should ensure the device inspection sticker is current as part of routine safety checks.

Postoperative Care

Monitoring for pain is crucial after administering hydromorphone.

Effective Client Teaching

Clients should be able to articulate the importance of medication adherence.

Managing Nursing Tasks

Developing an hourly time frame for tasks can help manage time effectively.

Client Assessment Findings

Identifying priority findings is essential during shift changes.

Understanding Medication Effects

Clients must understand the effects and side effects of their medications.

Determine goals of the day

Establish specific objectives for daily activities.

Magnesium sulfate via continuous IV infusion

A treatment for preeclampsia requiring careful monitoring.

Restrict the client's total fluid intake to 250 mL/hr

A guideline for fluid management in certain medical conditions.

Measure the client's urine output every hour

A critical action to monitor kidney function and fluid balance.

Give the client protamine if signs of magnesium sulfate toxicity occur

An emergency intervention for reversing magnesium toxicity.

Monitor the FHR via Doppler every 30 min

A procedure to assess fetal heart rate during labor.

Wounds healing by primary intention

Wounds that heal with minimal scarring, typically surgical incisions.

Approximated surgical incision

A type of wound expected to heal by primary intention.

Client taking clozapine to treat schizophrenia and reports sore throat

A priority client due to potential agranulocytosis risk.

Client has OCD and is upset about a change in daily routine

A client with stable condition, less urgent than others.

Client has narcissistic personality disorder and is mocking others during group therapy

A client displaying disruptive behavior, but not immediately life-threatening.

Client who has depressive disorder and requires assistance with ADLs

A client needing support but not in immediate danger.

Implanted venous access port

A device for long-term venous access in patients.

A non-coring needle

A specialized needle used to access implanted ports.

Client who has pneumonia and feels chest pain

A patient requiring urgent assessment for potential cardiac issues.

12 lead ECG

A priority diagnostic test for evaluating cardiac function.

Assessing growth and development of a 3 y/o child

Evaluating developmental milestones in early childhood.

Can your child ride a tricycle?

A question to assess gross motor skills in a 3-year-old.

Fetal heart tones assessment at 12 weeks of gestation

A procedure to monitor fetal health early in pregnancy.

Position the ultrasound stethoscope above the symphysis pubis to assess the FHR

A technique for detecting fetal heart tones during early pregnancy.

Chest tube with a water seal drainage system

A system used to manage pleural effusions or pneumothorax.

Tidaling in the water seal

Indicates that the chest tube system is functioning correctly.

The system is working properly

An indication that the drainage system is effectively managing fluid.

Heparin for DVT

A client who is receiving heparin for DVT should be recommended for early discharge.

HTN as contraindication

Hypertension (HTN) in the child's medical history is a contraindication for becoming a living kidney donor.

Lochia serosa

Lochia serosa is an expected assessment finding for a client who is 4 days postpartum.

Fundus 4 cm below umbilicus

A fundus 4 cm (1.6 in) below the umbilicus is an expected assessment finding for a client who is 4 days postpartum.

Postural drainage for cystic fibrosis

The nurse should perform postural drainage twice a day for a child with cystic fibrosis.

Oxygen tank safety

The oxygen tank should be placed away from curtains or drapes in a home care setting.

Seizure precautions for meningitis

Implementing seizure precautions is an action the nurse should take for a client with bacterial meningitis.

K 3.3 mEq/L

A potassium level of 3.3 mEq/L should be reported to the provider prior to hip arthroplasty.

Resetting suction drain

The nurse should reset the vacuum by compressing the container for a closed suction drain after a modified radical mastectomy.

Leukemia and platelet level

A client with leukemia and a platelet level of 95,000/mm3 should be assessed first.

Neonatal abstinence syndrome

A newborn experiencing neonatal abstinence syndrome is a concern for a mother who tested positive for heroin during pregnancy.

COPD and oxygen system

A home care nurse should ensure that the client checks the gauge of the compressed oxygen system weekly.

Postpartum assessment findings

The nurse should expect a foul perineal odor and a fundus displaced to the right as potential assessment findings.

Bronchodilator administration

A bronchodilator should be administered after the postural drainage procedure.

Fundus position postpartum

The fundus should be assessed for its position relative to the umbilicus in postpartum clients.

Oxygen tank storage

Oxygen tanks should not be stored under the bed.

Foul perineal odor

A foul perineal odor is an abnormal finding that may indicate infection postpartum.

Fundus displaced to the right

A fundus displaced to the right may indicate a full bladder postpartum.

Postpartum chill

A postpartum chill may occur as a normal physiological response.

Client with cancer and radiation therapy

A client with cancer who has a sealed implant for radiation therapy should be monitored for safety precautions.

IV Lasix and potassium level

A client who received IV Lasix and has a potassium level of 3.6 mEq/L is stable.

Blood glucose level

A blood glucose level of 80 mg/dL is within normal limits.

Na 142 mEq/L

A sodium level of 142 mEq/L is within normal limits.

PT 11.5 seconds

A prothrombin time (PT) of 11.5 seconds is within normal limits.

Minimize noise in the newborn's environment

An action the nurse should include in the care plan for a newborn.

Swaddle the newborn with his legs extended

A recommended practice for newborn care.

Administer naloxone to the newborn

A potential action for the nurse, depending on the newborn's condition.

Maintain eye contact with the newborn during feedings

A practice that fosters bonding and communication during feeding.

Change in the color of stool

A side effect expected by a client taking phenytoin.

Increase your intake of vitamin D while taking this medication

An appropriate nutritional instruction for a client prescribed phenytoin.

Plan to take this medication with antacids

A recommendation that is not appropriate for clients taking phenytoin.

Limit foods that contain folic acid while taking this medication

An incorrect instruction for a client taking phenytoin.

Presence of bloody show

A finding that does not indicate false labor.

Contraction intensity increased by ambulation

A sign that suggests true labor rather than false labor.

Slow change in dilation and effacement

A characteristic of false labor.

Intermittent, painless contractions

A manifestation of false labor.

Wash hands with alcohol based

An inappropriate action for a nurse caring for a client with C. diff.

Wear N95

Not required for C. diff precautions.

Remove thermometer from client's room for use on another client

An action that should not be taken when caring for a client with C. diff.

Change gloves after contact with infectious material

A necessary action for a nurse caring for a client with C. diff.

Wear a gown when providing care

An essential precaution when caring for a client with C. diff.

DM and HbA1C of 6.8%

A client condition that does not require immediate assessment.

Hip fracture and a new onset of tachypnea

A client condition that should be assessed first.

Epidural analgesia and weakness in lower extremities

A condition that may require assessment but is not the priority.

Sinus arrhythmia and is receiving cardiac monitoring

A client condition that does not require immediate assessment.

Medication requiring safe handling of biohazardous material spill

Doxorubicin hydrochloride.

Adverse effect of gentamicin

Creatinine 2.3 mg/dL.

Older adult who has BMI of 24

A client who does not require referral to a dietitian.

Client with albumin of 3.7 g/dL

A client who does not require referral to a dietitian.

Older adult who has presbyopia

A client who does not require referral to a dietitian.

Client who has a nonhealing leg ulcer

A client who should be referred to a dietitian.

Support group for clients whose family have committed suicide

A group session that should encourage clients to establish a timeline for their grieving process.

Assist clients in identifying ways suicide could have been prevented

An appropriate activity for the support group session.

Discourage clients from sharing negative aspects of their relationship with the deceased

Encourage clients to focus on positive memories and coping strategies.