ATI COMPREHENSIVE ATI A. LATEST 2022
ATI COMPREHENSIVE ATI A
1. A nurse in a LTC facility notces a client who has Alzheimer’s disease standing at
... [Show More] the exit door at the end of the
hallway. The client appears to be anxious & agitated. What acton should the nurse take?
ANS: Escort the client to a quiet area on the nursing unit.
- A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease
agitaton. They will be unable to follow instructons/commands.
2. A nurse is assistng with the plan of care for a client who has a contnent urinary diversion. Which interventon
should the nurse plan to implement to facilitate urinary eliminaton?
ANS: Use intermitent urinary catheterizaton for the client at regular intervals.
- A contnent urinary diversion contains valves that prevent urine from exitng the pouch; therefore, the nurse
should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.
3. A nurse is assistng with an educaton program about car restraint safety for a group of parents. Which statement
by the parent indicates an understanding of the instructons?
ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
- When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than
over the abdomen to reduce risk for injury during motor vehicle crash.
4. A nurse is reinforcing teaching about strategies to promote eatng with a client who has COPD. Which
instructons should the nurse include in the teaching?
ANS: Drink high-protein and high-calorie nutritonal supplements.
- The nurse should instruct the client to drink high-protein and high-calorie nutritonal supplements to maintain
respiratory muscle functon. COPD causes respiratory stress that leads to hypermetabolism and wastng of the
client’s muscle mass.
5. When removing PPE afer direct care for a client who requires airborne & contact precautons, which PPE is
removed frst?
ANS: Gloves
- The greatest risk is contaminaton from pathogens that might be present on the PPE; therefore, the priority
acton for the AP is to remove the gloves, which are considered the most contaminated.
6. A nurse is inspectng the skin of a newborn. Which fnding should the nurse report to the PCP?
ANS: Generalized Petechiae
- Petechiae are an expected fnding over the presentng part of the newborn, such as on the forehead in a brow
presentaton, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the
neck. However, petechiae all over the newborn’s body can indicate infecton or decreased platelet count and
should be reported to the provider.
7. A nurse is contributng to a teaching plan for a group of male adolescents about the A/E of anabolic steroid use.
Which manifestatons should the nurse include?
ANS: Reduced height potental
- Use of anabolic steroids in adolescence can lead to premature epiphyseal closure, thus reducing full height
potental. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne, and edema.
8. A nurse is reinforcing teaching with an older adult client who has severe L-sided HF. Which statement should the
nurse make?
ANS: Rest for 15 minutes between actvites.
- The nurse should instruct to increase his actvity gradually & to rest for a period of 15 min if he becomes tred.
Clients who have HF should balance actvity c rest to reduce cardiac workload.
9. A nurse in a LTC facility is documentng the care of an older adult client. Which informaton should be included in
weekly nursing care summary?
ANS: Hydraton Status
- Older adult client are at risk for dehydraton. Therefore, the nurse should be vigilant about monitoring the
client’s hydraton status & include this informaton in the weekly nursing care summary.10. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse
should obtain which informaton?
ANS: Motor Response
- The nurse should collect data about the client’s motor response & assign the response a score of 1-6, according
to the Glasgow Coma Scale.
11. A home health nurse is reinforcing teaching with a client about the use of elastc stockings to decrease peripheral
edema. Which instructon should the nurse include?
ANS: Apply the stocking in the morning.
- The nurse should instruct the client to apply the elastc stocking in the morning and remove them at the end of
the day before bedtme.
12. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterizaton in 2 days. Which
questons is the priority for the nurse to ask?
ANS: “Do you know if you’re allergic to iodine?”
- The greatest risk to the client is an allergic reacton to the contrast agent, which contains iodine.
13. A nurse is planning to administer nystatn oral suspension to a client who has oral candidiasis. Which instructons
should the nurse give?
ANS: “Hold the medicaton in your mouth for several minutes prior to swallowing”
- The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of the medicaton
with the organism. The client should then swallow or spit out the medicaton.
14. A nurse is preparing to care for the assigned clients on her upcoming shif. Which tme management strategies
should the nurse plan to use?
ANS: Prepare a priority list of client needs for the shif.
- The nurse should prepare a client priority-to-do list, which could include administering tme-critcal medicatons.
This will allow the nurse to determine which clients should receive care frst.
15. Afer witnessing the consent, what acton should the nurse take next?
ANS: Ask client what he understands about the procedure.
16. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee arthroplasty?
ANS: Reapply antembolitc stockings to the client ff a shower.
17. A nurse is reinforcing teaching with a client who is receiving radiaton therapy for cancer of the larynx. Which
statement made by the client indicates understanding of the teaching?
ANS: “I will wear a sof scarf around my neck when I am outside”
- Wash it with plain water without soap. NO heat source therapy. Only use electric razor if necessary, for shaving.
18. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who sis port-op. Which
factor should the nurse consider when using this pain scale?
ANS: Level Of Actvity
- The nurse should consider the infants level of actvity when using FLACC pain scale. The FLACC is determined by
fve categories of behavior: Facial Expression, Leg Movement, Actvity, and Consolability.
19. A nurse is collectng data from a 5YO child at a well-child visit. Parent reports that the child is having frequent
nightmares. Which statements by the parents indicates to the nurse that the child Is experiencing sleep terrors
rather than nightmares?
ANS: “My child goes back to sleep right away.”
- The nurse should realize that going back to sleep quickly is an indicaton of sleep terrors, rather than nightmares.
A child who is experiencing nightmare has difculty returning to sleep because of contnued fear.
20. A nurse is assistng with the care of a school-age child immediately ff surgery. The child weighs 21.8 kg (48 lb) &
has a chest tube applied to sucton. Which fnding should the nurse report to PCP?
ANS: 250 mL of sanguineous drainage over the last 3 hr
- More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutve hr ff surgery. It indicates
actve hemorrhaging.21. A nurse is reinforcing teaching with an older adult client who has osteoarthrits. Which instructons should the
nurse include?
ANS: Apply capsaicin cream 4x/day
- Apply it topically to provide warmth & relieve joint pain.
22. A nurse is reinforcing teaching about managing manifestaton of anxiety with a client who has generalized
anxiety disorder. Which informaton should the nurse include?
ANS: Say the word “STOP” when upsetng thoughts occur.
23. A nurse in a LTC facility is collectng data form a client who has been receiving betaxolol to treat glaucoma. Which
fndings is an A/E if this medicaton?
ANS: Bradycardia
- Betaxolol is a beta blocker that can produce systemic effects, including bradycardia.
24. A nurse in an outpatent surgery center is reinforcing discharge teaching with a client ff a lithotripsy for uric acid
stones. Which instructons should the nurse plan to include?
ANS: Strain the urine to collect stone fragments.
25. A nurse in a provider’s ofce is reinforcing teaching with a client who is to follow a 2,000 mg sodium-restricted
diet. Which client food selectons indicates understanding of the teaching?
ANS: Canned Peaches.
26. A nurse is preparing to perform a bladder scan for a client. Which acton should the nurse take?
ANS: Tell the client she should not experience any discomfort.
27. A nurse is contributng to the plan of care for a client who has a prescripton for ROM exercises of the shoulder.
Which exercise should the nurse recommend promotng shoulder hyperextension?
ANS: Move her arm behind her body with her elbow straight.
28. A nurse is collectng data from an older adult client who has a gastric ulcer. Which fnding should the nurse
identfy as a complicaton to report to the provider?
ANS: Hematemesis
29. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which statement by the newly
licensed nurse indicates understanding of this method of pain control?
ANS: “I should report leaking at the inserton site to the anesthesiologist”
30. A nurse is contributng to the plan of care for a client who is receiving contnuous bladder irrigaton immediately
ff a transurethral resecton of the prostate (TURP). Which of the ff interventons should the nurse include?
ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color.
31. A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is tearful & tells the nurse
that she is not ready to have this procedure done at this tme. What response should the nurse give?
ANS: “Would you like for me to talk to the surgeon with you?”
32. A nurse is collectng data from a school-age child who has hypoglycemia. What is the manifestaton to expect?
ANS: Sweatng
33. A nurse is assistng with a community educaton program for parents of preschoolers about recommended
actvites to promote physical development. Which of the ff statement should the nurse make?
ANS: “You should provide unorganized play actvites for your child each day.”
34. A nurse is collectng data from a client who has chronic pancreatts and is receiving pancrelipase. Which fndings
indicates the client is experiencing a therapeutc response to this medicaton?
ANS: Report of a decrease in the number of stools.
- Pancrelipase is administered as a replacement therapy for a defciency in pancreatc enzymes, which results in
steatorrhea, or faty stools.
35. A nurse is caring for a client who is 12-hour post-op ff total knee arthroplasty. What acton should the nurse
take?
ANS: Place an abducton wedge between the client’s legs when he is in bed.36. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female clients. Which
informaton should the nurse include in the teaching?
ANS: “You will gain weight before you start to get taller.”
37. NO ORAL CONTARCEPTIVES for CAD
38. A nurse is caring for a client who is at 34 weeks gestaton and has mild preeclampsia. Which fnding indicates a
progression from mild to severe preeclampsia?
ANS: Client reports of blurred vision.
39. A nurse is reinforcing teaching with a client who has asthma & has a prescripton of theophylline. What
statement should the nurse make?
ANS: Discontnue drinking caffeinated beverages.
40. A/E of metronidazole: Reddish-brown urine.
41. A home health nurse is collectng data from an older adult client who has generalized anxiety disorder. The client
lives at home with her partner & sibling. Which responses by the client’s partner is the priority for the nurse to
address?
ANS: “Her prescripton isn’t generic, so we can’t afford it anymore.”
42. Patent having difculty using eatng utensils. Refer patent to OT.
43. Child who have ingested full botle of acetaminophen, instruct parents to take the child to the ER
44. A client requestng informaton from a nurse about creatng a health care proxy. Which statement should the
nurse make?
ANS: “The person you appoint will make health care decisions for you if you cannot do so yourself.”
45. Venipuncture = antecubital fossa
46. The nurse should stop the infusion if the patent is having edema above the catheter inserton site.
47. A nurse is contributng to the plan of care for a client who has pneumonia. Which entries should the nurse
include in the plan?
ANS: “Client prefers bathing in the evening.”
48. Strategies to teach parents about pediculosis capits (Head lice) management:
ANS: Store child clothing in a separate cubicle when at school. Boil brushed and combs in water for 10 min. Dry
bed linens & clothing in a hot dryer for at least 20 min.
49. Caring for a client who has GTube. What actons should the nurse take?
ANS: Flush the tube with 50-60 mL of warm water if the tube becomes clogged.
50. Caring for client who is 4 hr post-op ff GI surgery & NG is placed for decompression. Which acton should the
nurse take?
ANS: Keep the plugged tube above the level of the stomach when the client is ambulatng.
51. Reinforcing teaching with a client who is scheduled for an exercise electrocardiography (ECG) stress test. What
instructon to give?
ANS: Recommend the client wear comfortable shoes during the test.
- Informed consent must be signed, Instruct client to eat 2-3 hr before test and then remain NPO to prevent GI
upset during test.
52. A client who is Orthodox Judaism with terminal illness. The nurse should assure the client family member will
stay with his body afer death.
53. A client who has pneumonia and is currently receiving oral antbiotc may be discharged to have more rooms for
new admission patent.
54. Avoid Ibuprofen when taking “PRIL” medicatons.
55. A nurse observes a client in labor. What interventons should the nurse recommend?
ANS: Squatng using a birth ball, Counter pressure to the sacral area, & leaning forward while kneeling.
56. Sitng and leaning forward using both hands for support is an expected fnding for a 7-month old infant.
57. Type 1 DM, patent indicates understanding of patent teaching when he/she states that, “I will dispose of my
needles in a plastc laundry detergent container”.
- It is puncture-proof!58. Offer client a whole grain cracker before bedtme if they are having difculty sleeping.
59. Red meat = iron
60. Peanut buter = protein
61. External rotaton is a clinical manifestaton to expect to a client with hip fx
62. “Let’s give the medicaton to your doll frst” is an acton the nurse should take prior to performing an
immunizaton to a preschooler.
63. Dark green and viscous is the stool to expect 24 hrs afer birth of an infant.
64. Atorvastatn A/E: Muscle Pain
65. Suggest walking outside with a staff member to a patent with bipolar disorder & in a manic phase.
66. An infecton with gonorrhea may result to infertlity. STI pt teaching
67. Physical neglect indicaton when collectng a from a toddler is when “the toddler is inadequately dressed for the
weather”
68. Overdose digoxin? Check VS
69. Anorexia Nervosa care plan? Record I&O
70. Documentng client care in the medical record, entries to include would be “Client remains NPO untl X-Ray
procedure is complete”
71. To initate Babinski reflex? Stroke the sole of the infant’s foot upward & toward the great toe.
72. Report an ECG result with PR interval 0.24 seconds.
73. When patent report of nuchal rigidity, H/A, along with fever & chills. The nurse should antcipate the MD to
order what diagnostc tests?
ANS: Cerebrospinal fluid analysis
- The client fndings are consistent with bacterial meningits. A lumbar puncture should be performed to obtain
cerebrospinal fluid to confrm the diagnosis.
74. Post-Op Lumbar puncture: Instruct patent to increase fluid intake.
75. The client must take montelukast once daily at bedtme.
76. Perform daily gum massage when taking phenytoin as a measure to assist with the possible A/E.
77. Lung sound: Wheezes
78. Morphine A/E: Respiratory Rate of 10/min
79. Document fndings as a variance
80. pH 7.5 is a complicaton of mechanical ventlaton
81. Recent confrmaton of pregnancies
82. Spaghet with red meat sauce
83. Urine specifc gravity of 1.002 for pt with DI
ATI comprehensive:
1. 4hr postpartum, boggy uterus with heavy lochia. Which of the following actons should the nurse take?
Massage the uterus to expel clots
Ratonale: ABC approach, priority is to massage uterus to expel clots and increase uterine frmness,
resultng in decreased bleeding
2. Defcit in Cranial nerve 2: results in visual impairment and lead to falls
clear objects from the walking area
3. indicate the progression of labor and are a benign finding
-nurse should continue to monitor FHR
4. Review ABGs
5. A nurse is interviewing a client who has just lost her home due to a natural disaster. After
ensuring the client's safety, which of the following actions should the nurse take frst?
Determine the client's perception of the personal impact of the crisis
First thing in the nursing process is assessment so assess client’s feelings and understanding of the natural
disaster and its personal impact6. An assistive personnel (AP) and a nurse are turning a client on to her right side. Which of
the following actions by the AP requires the nurse to intervene?
Places a pillow under the client's right arm
7. A nurse in a community center is providing an educational session to a group of women about ovarian cancer. For
which of the following manifestations should the nurse instruct the women to contact their providers?
Abd bloating
The nurse should include the presence of abdominal bloating as an early indication of ovarian cancer as
well as other manifestations which include an increase in abdominal girth, pelvic or abdominal pain, early
satiety, and urinary frequency or urgency.
8. Hypokalemia
signs and symptoms: muscle weakness and decreased deep tendon reflexes
9. Hypocalcemia
numbness and tngling of the extremites and around the mouth
10. Car safety, d/c teaching
secure the retainer clip at the level of your baby’s armpits
The nurse should instruct the client to secure the retainer clip at the level of the newborn's axillae. The
bones of the rib cage and sternum provide protection to underlying organs in the event of a collision.
Placing the clip on the abdomen increases the risk for injury to internal organs.
11. Nurse in ED is admitting a client who has cardiac tamponade, which assessment finding should the nurse expect?
pulsus paradoxus
The nurse should identify pulsus paradoxus, a fnding in which the systolic BP is 10 mm Hg or greater on
expiration than inspiration, as an expected fnding of cardiac tamponade, along with jugular vein
distention, bradycardia, and hypotension.
12. Allowable foods for a client who has a hx of uric-acid based urinary calculi formation. Which of the following
foods should the nurse recommend that the client include in his diet?
Citrus fruits such as oranges
Avoid animal-based proteins and alcohol
13. A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints.
Which of the following actions should the nurse take to provide comfort to this client?
Allow for frequent rest periods throughout the day
To maintain muscle strength, joint function and ROM
Warm shower instead of warm TUB baths
14. first trimester with an acupressure on wrist, indicates that this therapy is having desired effects?
I have not vomited for the past two weeks
Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies
pressure to a specifc part of the body the client can use to alleviate nausea and vomiting.
15. Risk of development of a pressure ulcer?
Recent weight loss
16. 4hr post op following a total vaginal hysterectomy, actions to take first?
Measure client’s VS
The frst action the nurse should take when using the nursing process is to assess the client. The [Show Less]