ATI EXAM zm
Exam Solution zm
RN Comprehensive Online B Exam Questions and Answ
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ers (Verified Answers) Most Recent exam COMPLETE (
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) (Latest Update ) UPDATE!! 2026 A+ GRADE ASSURED
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COMPLETE SOLUTIONS AND VERIFIED ANSWERS (87B zm zm zm zm zm
99)
QUESTION 1 zm
A nurse is assessing a client after administering epinephrine for an anaphylactic react
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ion. Which of the following findings should the nurse identify as an adverse effect of t
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his medication?
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A. Hypotension
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B. Report of tinnitus
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C. Report of chest pain
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D. Ecchymosis
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ANSWER
Report of chest pain The nurse should identify that a report of chest pain by the client can indicate
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an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, wh
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ich can result in angina. Incorrect Hypertension is an adverse effect of epinephrine due to the vasoc
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onstrictive actions of epinephrine. Tinnitus is not an adverse effect of epinephrine. Ecchymosis is not
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an adverse effect of epinephrine.
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QUESTION 2 zm
A nurse is caring for an older adult client in the PACU following general anesthesia. W
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hich of the following findings should the nurse report to the provider?
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A. Urine output 120 mL in 4 hr
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B. Systolic blood pressure 12 mm Hg lower than the preoperative level
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C. Audible stridor
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D. Normal sinus rhythm with an occasional premature ventricular contraction
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ANSWER
,Audible stridor Audible stridor, or a high-
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pitched sound heard in the client's airway, indicates edema, laryngeal spasm, secretions, or some typ
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e of airway obstruction that could become life-
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threatening. The nurse should report this finding to the provider. Incorrect The nurse should monito
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r urinary output and report any amount less than 30 mL/hr. The nurse should report blood pressur
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e changes that are greater than a 15 to 20 mm Hg difference from the client's baseline blood pressu
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re. Anesthesia medications and surgery, especially in older adult clients, are common causes of prem
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ature ventricular contractions. The nurse should monitor the frequency of the premature ventricular
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mcontractions but does not need to report this finding to the provider.
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QUESTION 3 zm
A nurse is admitting a client to the mental health unit after an attempted suicide. The
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client states, "My family does not care whether I live or die." Which of the following r
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esponses should the nurse make? zm zm zm zm
A. "I'm sure your family does not want you to die."
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B. "Why would you believe such things?"
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C. "How does this make you feel?"
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D. "You should talk to your family about your feelings."
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ANSWER
"How does this make you feel?" This response encourages the client to evaluate their feelings. Incorr
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ect This response provides false reassurance and minimizes the client's feelings. This response critici
zm zm zm zm zm zm zm zm zm zm zm zm zm
zes the client and might result in the client feeling defensive. This response gives the client advice a
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nd inhibits problem-solving.
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QUESTION 4 zm
A nurse is performing tracheostomy care for a client who is postoperative following a
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laryngectomy. Which of the following actions should the nurse take when suctioning t
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he client's airway?
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A. Withdraw the catheter if the client begins coughing.
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B. Apply suction for 10 seconds.
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C. Advance the catheter 2 cm (0.8 in) after resistance is met.
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D. Use medical asepsis when performing the procedure.
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ANSWER
Apply suction for 10 seconds. The nurse should apply suction for only 5 to 15 seconds to minimize
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
oxygen loss. Incorrect Suctioning can initiate the cough reflex as it opens the airway further and allo
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ws for more effective removal of mucus. Once resistance is met, the nurse should withdraw the cath
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
eter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues. The nurse should use surgic
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
al asepsis when suctioning a newly created tracheostomy to reduce the risk for infection.
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QUESTION 5 zm
, A nurse is caring for a client who has a deep vein thrombosis. Which of the following
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actions should the nurse take? zm zm zm zm
A. Teach the client to massage the affected extremity.
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B. Instruct the client to elevate the affected extremity when sitting.
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C. Assess pulses proximal to the affected area.
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D. Apply a cold compress to the affected extremity.
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ANSWER
Instruct the client to elevate the affected extremity when sitting. The nurse should instruct the client
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to elevate the affected extremity when in the bed or chair. Incorrect Massaging the affected extremi
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ty increases the risk of dislodging the thrombus and causing an embolus that can travel to the lungs
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. The nurse should assess pulses distal to the affected area. The nurse should apply warm, moist co
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mpresses to the affected extremity. zm zm zm zm
QUESTION 6 zm
A nurse is providing teaching to a parent of a child who has a permanent tracheostom
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y tube. Identify the sequence of steps the parent should follow to perform tracheosto
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my care. zm
ANSWER
- Remove the inner cancula - Remove the soiled dressing -
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Clean the stoma with 0.9% sodium chloride - Change the tracheostomy collar
zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 7 zm
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the foll
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owing actions is the nurse's priority?
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A. Assess fluid intake every 24 hr.
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B. Ambulate three times a day.
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C. Assist with deep breathing and coughing.
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D. Monitor the incision site for findings of infection.
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ANSWER
Assist with deep breathing and coughing. The priority action the nurse should take when using the
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
airway, breathing, circulation approach to client care is to assist the client with deep breathing and
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
coughing, which reduces the risk for postoperative pneumonia. Incorrect The nurse should assess th
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e client's fluid intake every 24 hr to evaluate hydration status. However, another action is the nurse'
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
s priority. The nurse should ambulate the client three times a day to promote circulation. However,
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another action is the nurse's priority. The nurse should monitor the client's incision site for findings
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mof infection. However, another action is the nurse's priority.
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QUESTION 8 zm
Exam Solution zm
RN Comprehensive Online B Exam Questions and Answ
zm zm zm zm zm zm zm
ers (Verified Answers) Most Recent exam COMPLETE (
zm zm zm zm zm zm zm
) (Latest Update ) UPDATE!! 2026 A+ GRADE ASSURED
zm zm zm zm zm zm zm zm zm
COMPLETE SOLUTIONS AND VERIFIED ANSWERS (87B zm zm zm zm zm
99)
QUESTION 1 zm
A nurse is assessing a client after administering epinephrine for an anaphylactic react
zm zm zm zm zm zm zm zm zm zm zm zm
ion. Which of the following findings should the nurse identify as an adverse effect of t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
his medication?
zm
A. Hypotension
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B. Report of tinnitus
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C. Report of chest pain
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D. Ecchymosis
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ANSWER
Report of chest pain The nurse should identify that a report of chest pain by the client can indicate
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, wh
zm zm zm zm zm zm zm zm zm zm zm zm zm
ich can result in angina. Incorrect Hypertension is an adverse effect of epinephrine due to the vasoc
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
onstrictive actions of epinephrine. Tinnitus is not an adverse effect of epinephrine. Ecchymosis is not
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
an adverse effect of epinephrine.
zm zm zm zm zm
QUESTION 2 zm
A nurse is caring for an older adult client in the PACU following general anesthesia. W
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
hich of the following findings should the nurse report to the provider?
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A. Urine output 120 mL in 4 hr
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B. Systolic blood pressure 12 mm Hg lower than the preoperative level
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C. Audible stridor
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D. Normal sinus rhythm with an occasional premature ventricular contraction
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ANSWER
,Audible stridor Audible stridor, or a high-
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pitched sound heard in the client's airway, indicates edema, laryngeal spasm, secretions, or some typ
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e of airway obstruction that could become life-
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threatening. The nurse should report this finding to the provider. Incorrect The nurse should monito
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
r urinary output and report any amount less than 30 mL/hr. The nurse should report blood pressur
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e changes that are greater than a 15 to 20 mm Hg difference from the client's baseline blood pressu
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
re. Anesthesia medications and surgery, especially in older adult clients, are common causes of prem
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ature ventricular contractions. The nurse should monitor the frequency of the premature ventricular
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mcontractions but does not need to report this finding to the provider.
zm zm zm zm zm zm zm zm zm zm zm
QUESTION 3 zm
A nurse is admitting a client to the mental health unit after an attempted suicide. The
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
client states, "My family does not care whether I live or die." Which of the following r
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esponses should the nurse make? zm zm zm zm
A. "I'm sure your family does not want you to die."
zm zm zm zm zm zm zm zm zm zm
B. "Why would you believe such things?"
zm zm zm zm zm zm
C. "How does this make you feel?"
zm zm zm zm zm zm
D. "You should talk to your family about your feelings."
zm zm zm zm zm zm zm zm zm
ANSWER
"How does this make you feel?" This response encourages the client to evaluate their feelings. Incorr
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ect This response provides false reassurance and minimizes the client's feelings. This response critici
zm zm zm zm zm zm zm zm zm zm zm zm zm
zes the client and might result in the client feeling defensive. This response gives the client advice a
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
nd inhibits problem-solving.
zm zm
QUESTION 4 zm
A nurse is performing tracheostomy care for a client who is postoperative following a
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laryngectomy. Which of the following actions should the nurse take when suctioning t
zm zm zm zm zm zm zm zm zm zm zm zm
he client's airway?
zm zm
A. Withdraw the catheter if the client begins coughing.
zm zm zm zm zm zm zm zm
B. Apply suction for 10 seconds.
zm zm zm zm zm
C. Advance the catheter 2 cm (0.8 in) after resistance is met.
zm zm zm zm zm zm zm zm zm zm zm
D. Use medical asepsis when performing the procedure.
zm zm zm zm zm zm zm
ANSWER
Apply suction for 10 seconds. The nurse should apply suction for only 5 to 15 seconds to minimize
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
oxygen loss. Incorrect Suctioning can initiate the cough reflex as it opens the airway further and allo
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ws for more effective removal of mucus. Once resistance is met, the nurse should withdraw the cath
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
eter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues. The nurse should use surgic
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
al asepsis when suctioning a newly created tracheostomy to reduce the risk for infection.
zm zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 5 zm
, A nurse is caring for a client who has a deep vein thrombosis. Which of the following
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actions should the nurse take? zm zm zm zm
A. Teach the client to massage the affected extremity.
zm zm zm zm zm zm zm zm
B. Instruct the client to elevate the affected extremity when sitting.
zm zm zm zm zm zm zm zm zm zm
C. Assess pulses proximal to the affected area.
zm zm zm zm zm zm zm
D. Apply a cold compress to the affected extremity.
zm zm zm zm zm zm zm zm
ANSWER
Instruct the client to elevate the affected extremity when sitting. The nurse should instruct the client
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
to elevate the affected extremity when in the bed or chair. Incorrect Massaging the affected extremi
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ty increases the risk of dislodging the thrombus and causing an embolus that can travel to the lungs
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
. The nurse should assess pulses distal to the affected area. The nurse should apply warm, moist co
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
mpresses to the affected extremity. zm zm zm zm
QUESTION 6 zm
A nurse is providing teaching to a parent of a child who has a permanent tracheostom
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y tube. Identify the sequence of steps the parent should follow to perform tracheosto
zm zm zm zm zm zm zm zm zm zm zm zm zm
my care. zm
ANSWER
- Remove the inner cancula - Remove the soiled dressing -
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Clean the stoma with 0.9% sodium chloride - Change the tracheostomy collar
zm zm zm zm zm zm zm zm zm zm zm zm
QUESTION 7 zm
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the foll
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
owing actions is the nurse's priority?
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A. Assess fluid intake every 24 hr.
zm zm zm zm zm zm
B. Ambulate three times a day.
zm zm zm zm zm
C. Assist with deep breathing and coughing.
zm zm zm zm zm zm
D. Monitor the incision site for findings of infection.
zm zm zm zm zm zm zm zm
ANSWER
Assist with deep breathing and coughing. The priority action the nurse should take when using the
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
airway, breathing, circulation approach to client care is to assist the client with deep breathing and
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
coughing, which reduces the risk for postoperative pneumonia. Incorrect The nurse should assess th
zm zm zm zm zm zm zm zm zm zm zm zm zm
e client's fluid intake every 24 hr to evaluate hydration status. However, another action is the nurse'
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
s priority. The nurse should ambulate the client three times a day to promote circulation. However,
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
another action is the nurse's priority. The nurse should monitor the client's incision site for findings
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
mof infection. However, another action is the nurse's priority.
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QUESTION 8 zm
