ATI PN COMPREHENSIVE EXIT RETAKE EXAM
180 NGN QUESTIONS AND VERIFIED ANSWERS & RATIONALES
WELL GRADED, BEST ATI COMPREHENSIVE
1. A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two
fingerbreadths above the umbilicus.Oxytocin 20 units being administered via
continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling
anxious. Skin cool and clammy. Provider notified.
Exhibit 2
,Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory: Select the 6 actions the
nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter. Administer
methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask. Firmly
massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine fundus,
administer methylergonovine, weigh the perineal pads, provide emotional support, insert an
indwelling urinary catheter, and administer oxygen at 12 L/min via nonrebreather face mask.
The nurse should identify that the client is experiencing a postpartum hemorrhage, which
requires immediate intervention to prevent hemor- rhagic shock.
2. A nurse is collecting data from a client who is scheduled for surgery. Exhibit
,1
Vital Signs 0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood
pressure 122/76 mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood
pressure 128/78 mmHgOxygen saturation 95% on room air
,Exhibit 2
Nurses' Notes
0630:
Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the
last week. Cli: Click to highlight the data collection findings that the nurse should report to
the provider prior to the procedure. To deselect a finding, click on the finding again.
Hemoglobin level Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should determine the client's
hemoglobin level, latex allergy, and family history of malignant hyperther- mia should be
reported to the provider. When the client's hemoglobin level is below the expected range, the
client might require blood products during the intraoperative phase. The client's allergy to
avocados and bananas can indicate an allergy to latex products and should be reported to the
provider. The surgical team will need to remove all latex products from the operating room.
During the intraoperative phase, the nurses must be diligent in monitoring the client's vital
signs and laboratory values, especially in a client who has a family history of malignant
hyperthermia.
,3. A nurse is caring for a client who is recovering from a stroke and is experi- encing
difficulty using eating utensils. The nurse should identify the need for a referral to
which of the following interprofessional team members
Ans>> Occupa- tional therapist
The nurse should identify the need for a referral to an occupational therapist to teach the client
how to use special eating utensils.
4. A nurse is reviewing the electronic health records of four clients. Which of the
following client conditions should the nurse recognize as reportable to a regulatory
agency
Ans>> A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as tuberculosis, require
notification of the local and state health departments.
5. A nurse is caring for a client who is being discharged home following a
cerebrovascular accident. Which of the following documents should the nurse plan to
include with the discharge report
,Ans>> List of potential complications to
,report
Discharge instructions are defined as any form of documentation provided to the client, upon
discharge to home, which facilitates safe and appropriate continuity of care. The nurse should
plan to include a list of potential complications that should be reported to the provider in the
client's discharge instructions.
6. A nurse is reinforcing teaching with the parent of a preschooler who has lactose
intolerance. Which of the following statements by the parent indicates an
understanding of the teaching
Ans>> "I should offer my child yogurt that has a probiotic as a snack."
Children who have lactose intolerance should be offered dairy products that have a probiotic,
such as lactobacillus. The probiotic promotes tolerance of lactose in the colon.
7. A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which of
the following client statements indicates an understanding of the teaching
Ans>> "I should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely. Change in appetite
can be an early sign of hyperglycemia and inadequate intake may cause blood glucose to drop.
,8. A nurse is collecting data from a client who has iron deficiency anemia. Which of
the following findings should the nurse expect
Ans>> Difficulty concentrat- ing
In clients who have iron deficiency anemia, body cells do not receive the required oxygen
because there is less hemoglobin for binding. The nurse should recognize that impaired
oxygenation of brain tissue can lead to dizziness and difficulty con- centrating.
9. A nurse is caring for a client who is immunocompromised. Which of the fol- lowing
immunizations is contraindicated
Ans>> Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
10. A nurse is caring for a client who has expressive aphasia following a stroke. Which
of the following methods should the nurse use when communi- cating with the client
Ans>> Provide a picture board.
,A client who has expressive aphasia has difficulty expressing needs or wants
through verbalization or writing. The use of a picture board provides an alternative means of
communication that might be less frustrating for the client.
11. A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the needle
on the counter's surface. Which of the following actions should the nurse take
Ans>> Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure
the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a
new syringe and new dose of insulin.
12. A nurse is checking the reflexes of a newborn. Which of the following techniques
should the nurse use to elicit the Babinski reflex
Ans>> Stroke the sole of the newborn's foot upward and toward the great toe.
The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at
the heel, to elicit the Babinski reflex.
13. A nurse is administering morning medications to a client. The client ques- tions
the nurse regarding a medication that they do not recognize. Which of the following
, actions should the nurse take first
Ans>> Verify the prescription in the client's medical record.
The first action the nurse should take when using the nursing process is to collect more data.
By verifying the prescription in the client's medical record, the nurse can ensure that the
medication is prescribed for the client.
14. A client in a mental health facility accuses a nurse of stealing money from their
room. Which of the following therapeutic responses should the nurse make
Ans>> Tell me how you decided who took your money."
This response by the nurse is an example of therapeutic communication, in which the nurse
validates the client's concern by encouraging them to describe their perception
15. A nurse is reinforcing teaching for a client who is preparing to return to work after
a back injury. Which of the following instructions for safe lifting technique should the
nurse include
Ans>> "You should hold a box close to your body when lifting it up."
10 /
42
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller LectWoody. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $22.49. You're not tied to anything after your purchase.
