VERSION 2
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following
interventions should the nurse include in the plan of care?
a. Give acetaminophen
...
VERSION 2
1. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following
interventions should the nurse include in the plan of care?
a. Give acetaminophen to control the child’s fever
b. Monitor the client’s cardiac status (PEDS p120)
c. Administer antibiotics via intermittent IV bolus for 24 hrs.
d. Provide stimulation with children of the same age in the play room
2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, “The voices are telling
me to jump.” Which of the following is an appropriate response by the nurse?
a. “Do you recognize the voices as belonging to anyone you know?”
b. “I understand the voices are frightening you, but I do not hear any voices.”
c. “That can’t be true. The only voices in this room are yours and mine.”
d. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.”
3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an
understanding of advance directives? (Select all that apply.)
a. “I need an attorney to witness my signature on the advance directives.” *(nurse witnesses it)
b. “I have the right to refuse treatment.” (Leadership p38)
c. “My doctor will need to approve my advance directives.” (just needs to write a prescription)
d. “My health care proxy can make medical decisions for me.” (Leadership p38)
e. “I can’t change my advance directives once submitted.” (yes, you can)
4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrives. Which of the
following statements by the nurse is appropriate?
a. “Offer your son a gift when the baby receives one.” (Provide a gift from the infant to give the sibling)
b. “Teach your son to change the baby’s diapers.” (Allow older siblings to help in providing care for the infant)
c. “Tell your son to kiss the baby.” (Maternity p126: Let the sibling be one of the first to see the infant)
d. “Move your son to a toddler bed when the baby arrives. (do this weeks prior to baby’s arrival)
5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should
the nurse include in the teaching?
a. Limit total daily sodium intake to 4 to 5 grams
B. Obtain most calories from complex carbohydrates (for CKD)
c. Consume a high-protein diet (High protein, high potassium, low sodium)
d. Avoid intake of soy products.
6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of
the following is an appropriate question by the nurse?
a. “Did you think about removing yourself from the situation when you became angry?”
b. “Why do you get angry when things don’t go your way?”
c. “How do you think others feel when you express anger?”
D. “What are you thinking about when you express anger?” (assessing the underlying issue of aggression)
7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the
following should the nurse include in the plan of care?
a. Wear a dosimeter film badge while in the client’s room. (Med Surg p583)
b. Ensure family members remain at least 3 feet from the client (should be at least 6ft)
c. Limit each of the client’s visitors to 1 hrs. per day. (should be 30 minutes)
d. Remove dirty linens from the room after double bagging.
COMPREHENSIVE 2
8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to
take?
a. Sit at or below the client’s eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks
or other areas of the mouth)
b. Talk with the client during her feeding
c. Discourage the client from coughing during feedings (encourage pt. to cough to prevent aspiration)
d. Instruct the client to lift her chin when swallowing (tuck chin)
9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate
dehydration?
a. Bradypnea
B. Oliguria (Funds p343)
c. Diaphoresis
d. Excessive tears
10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include
in the teaching?
a. “Your child can return to school after a negative titer result.”
b. “Your child can return to school 24 hours after beginning antibiotics.”
c. “Your child can return to school once the lesions have crusted over.” REPEAT 2016
d. “Your child can return to school once the fever has subsided.”
11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the
nurse instruct the client to monitor and report to the provider?
a. Muscle weakness- rhabdomyolysis
b. Edema
c. Weight loss
d. Fever
12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?
a. A client who is receiving warfarin and has an INR of 3.3
b. A client who had an NG tube inserted 6 hrs. ago and has abdominal distention
c. A client who is 4 hrs. postoperative following a thyroidectomy and reports fullness in the back of the throat (edema
can lead to resp. distress)
d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL
13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?
a. A client who reports changing her perineal pad every 2 hrs.
b. A client who reports abdominal pain during breastfeeding
c. A client who has a urine output of 250 mL in 6 hrs.
d. A client who has hyporeflexia while receiving magnesium sulfate REPEAT
14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid
calculi. Which of the following should the nurse include in the teaching?
a. Roast beef
b. Chicken breast
c. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry)
d. Tuna fish
COMPREHENSIVE 3
15. A nurse in the emergency department is caring for a client who has a 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?
a. Preventing infection
b. Offering emotional support
c. Providing pain management
d. Initiating IV fluid resuscitation - REPEAT
16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results
with her partner. Which of the following is an appropriate response for the nurse to make? REPEAT
a. “The provider will be tactful when talking to your partner.”
b. “You have the right to decide who receives information.”
c. “Is there a reason you don’t want your partner to know about your procedure?”
d. “Your partner can be a great source of support for you at this time.”
17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury.
Which of the following recommendations should the nurse include in the teaching?
a. Provide low-calcium foods
b. Provide high-phosphorus foods
c. Provide low-potassium foods
d. Provide high-sodium foods
18. A nurse is planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which of the
following actions should the nurse include in the plan of care? REPEAT
a. Apply a warm compress to the operative site every 4 hrs.
b. Offer small amounts of clear liquids 6 hrs. following surgery
c. Give cromolyn nebulized solution every 8 hrs.
d. Administer analgesics on a scheduled basis for the first 24 hrs.
19. A nurse is assessing a client who is 8 hrs. postpartum and has been unable to void. Which of the following actions should the
nurse take first?
a. Pour warm water over the client’s perineum
b. Offer the client a Sitz-bath
c. Insert a sterile catheter
d. Administer an analgesic
20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin.
Which of the following statements by the nurse is appropriate?
a. “Limit foods that contain folic acid while taking this medication.”
b. “You should expect a change in the color of your stool while taking this medication.”
c. “Increase your intake of vitamin D while taking this medication.” - phenytoin complication (bone pain and weakness)
d. “Plan to take this medication with antacids.”
21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings
indicates the client is experiencing a fat embolism?
a. Petechiae on the chest and abdomen ! practice test 2016 A
b. Decreased pedal pulses
c. Pain unrelieved by opioid analgesics
d. Crepitus at the knee joint
22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the
nurse include in the teaching?
COMPREHENSIVE 4
a. “You will have a Doppler transducer applied to your abdomen during the test.”
b. “You should massage one of your nipples to stimulate contractions of your uterus.”
c. “You will need blood work before and after the test.”
d. “You should avoid eating or drinking for 4 hrs. before the test.”
23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of
the following is the priority admission data for the nurse to obtain?
a. Changes in appetite
b. Daily fluid intake
c. Swallowing ability - aspirations precautions
d. Prescribed medications
24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the
following statements should the nurse include in the teaching?
a. “Eat a diet rich in fresh fruits and vegetables.”
b. “Wear disposable gloves under gardening gloves while working with house plants.”
c. “Children may visit as long as they’ve recently received a live influenza vaccination.”
d. “Check your temperature weekly.”
BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID
25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of
the following actions should the nurse take? REPEAT
a. Maintain the client in supine position for the first 24 hrs.
b. Secure the drain to the bedding
c. Reset the vacuum by compressing the container
d. Position the affected extremity below the level of the client’s heart
MAIN VERSION PRIORITY ONE
1. Missing
2. A nursing planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which
of the following actions should the nurse include in the plan of care?
a. Offer small amounts of clear liquids 6 hrs. following surgery (assess for gag reflex first)
b. Give cromolyn nebulizer solution every 6 hrs. (for asthma)
c. Apply a warm compress to the operative site every 4 hrs.
d. Administer analgesics on a scheduled basis for the first 24 hrs.
Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short term (24 to 48 hrs.)
around the clock administration of opioids is preferable to following a PRN schedule.
ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated
on ATI.
3. 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?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR, decreased O2, headache,
decreased LOC r/t low O2 levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures
are common causes, can occur after injury usually within 12-48 hrs.
COMPREHENSIVE 40
4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the
nurse take?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote absorption; avoid
oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hrs. of removing it from the protective pouch (apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed together)
Rationale https://medlineplus.gov/druginfo/meds/a601084.html: How to apply patch
Rationale ATI Skills Module Medication Administration: Topical medications include lotions, creams,
ointments, patches, and paste. Because topical medications are absorbed by the skin, wear gloves when applying
them to protect yourself against accidental exposure
Shaving may cause skin irritation and change the absorption of the drug.
5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse
assess first?
a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hrs. (can wait)
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
d. A client who received a pain medication 30 min ago for postoperative pain
Rationale Med Surg ATI PDF p529: assess for improvement or worsening of hypoglycemia. Repeat the
administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure
& coma if condition worsens.
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the
client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
Rationale ATI MS p309: Complications: Aspiration of gastric secretion, causes: Reflux of gastric fluids into the
esophagus can be aspirated into the trachea.
7. A nurse is reviewing the laboratory results for a client who has Cushing’s disease. The nurse should expect the client
to have an INCREASED in which of the following laboratory values?
a. Serum glucose level- increased
b. Serum calcium level-decreased
c. Lymphocyte count- decreased immune system.
d. Serum potassium level- decreased
Rationale ATI MS PDF p518: Cushing disease" everything is UP except Potassium & Calcium: DECREASED.
8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The
nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions
should the nurse take? Pg. 235 pharm Ch. 30
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate toxicity. Always have an
injectable form of calcium gluconate available when administering magnesium sulfate by IV.
COMPREHENSIVE 41
9. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of
the following risk factors should the nurse include as the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison
Rationale ATI MH p185: Risk factors also include: past history of aggression, poor impulse control, and
violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry
reactions with cognitive disorders).
Rationale ATI COMMUNITY p50: Individual Assessment for Violence
10. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when
setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body" flap AWAY from the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field " 2.5 cm (1-inch) border around any
sterile drape or wrap that is considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level" it says BELOW waist level; should be ABOVE waist level
Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap from bottle in upward
motion.
11. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the
following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hrs. if unable to fall asleep
c. Take a 1 hrs. nap during the day
d. Perform exercises prior to bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following
actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up appointments
Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following
questions should the nurse ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from?”
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
Rationale ATI How to assess “remote memory”? Have patient state a verifiable fact (e.g. birthdate). OR ask the
client to state a fact from their past that is verifiable.
Memory of events that occurred in the distant past.
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should
the nurse include in the teaching? P .528 med surg Ch. 82
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > 8 means NON-COMPLIANT
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC
COMPREHENSIVE 42
d. HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new
prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia
and incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under control
c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
Rationale: http://www.webmd.com/drugs/2/drug-4157/dilantin-oral/details#interactions
Rationale ATI Pharm p96: Phenytoin complications include ataxia, sedation & cognitive impairment
(http://emedicine.medscape.com/article/816447-clinical#b4 also states that this is an indication of phenytoin
toxicity); According to my Davis Drug Guide book, progressive s/s of phenytoin toxicity include ataxia, nystagmus,
confusion, nausea, slurred speech & dizziness.
16. A nurse is caring for a client who is 1 hrs. postoperative following rhinoplasty. Which of the following manifestations
requires immediate action by the nurse?
a. Increase in frequency of swallowing" may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face" side effect
d. Absent gag reflex" possibly due to anesthesia given. (1 hour postoperative)
Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following
interventions should the nurse include in the plan of care?
a. Give scheduled doses of acetaminophen every 6 hrs.
b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hrs.
d. Provide stimulation with children of the same age in the playroom
Rationale ATI PDF p: PEDS p. 120 Monitor VS, cardiac status. Maintain cardiac monitoring. Assess for HF
(decrease urine output, gallop heart rhythm, tachycardia, respiratory distress)
Kawasaki disease cause inflammation in the walls of medium-sized arteries throughout the body. It primarily
affects children. The inflammation tends to affect the coronary arteries, which supply blood to the heart muscle.
18. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following
potential consequences of smoking is most likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer later in life
c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
Rationale ATI PDF p:33 PEDS Age appropriate activities for high school students: sports, video games, music,
social events.
19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the
nurse monitor for this client? Pg. 146 Ch. 19 CONFIRMED
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
COMPREHENSIVE 43
20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the
following statements by the nurse indicates an understanding of this role?
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.”
c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.”
Rationale ATI PDF p: Makes most sense (best rationale yet)
21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse
report to the provider? Pg. 156 Ch. 23 MATERNITY PDF
a. A two-day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal they can be is
RESPIRATORY DISTRESS
b. A 16-hour old new newborn who has yet to pass meconium- you got 24 hours to pass stool
c. A 2-day old newborn who has a small amount of blood tinged vaginal discharge
d. A 16 hrs. old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse
assess first? Pain pallor pulselessness paresthesia
a. A client who is 1 hrs. postoperative and has hypoactive bowel sounds
b. A client who has fractured left tibia and pallor in the affected extremity
c. A client who had a cardiac catheterization 3 hrs. ago and has 3+ pedal pulses
d. A client who has an elevated AST level following administration of azithromycin
Rationale: circulation is affected; ABCs
23. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the
following adverse effects should the nurse instruct the client to report to the provider?
a. Dry mouth" anticholinergic effects
b. Sedation "
c. Shuffling gait !A/E EPS: is an indication of parkinsonism and should be reported to the provider. ATI PHARM
110
Rationale: e book pg. 69 Ch. 10
24. A nurse is planning discharge teaching about cord care for the
parents of a newborn which of the following instructions should the
nurse plan to include in the teaching? Pg. 177 Ch. 26
a. Clean the base of the cord with hydrogen peroxide daily- only
with tub and sponge baths
b. The cord stump will fall off in 5 days- about 10 - 14 days
c. Contact the provider if the cord stump turns black
d. Keep the cord stump dry until it falls off
Rationale: cord usually falls out within 7 to 10 days. Clean with soap
and water. Cord is expected to turn black and dry.
25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is
appropriate for the client?
a. White flour tortillas
b. Potato pancakes
c. Wheat crackers
d. Canned barley soup
Rationale: no wheat, flour, or barley
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