ATI RN COMPREHENSIVE EXIT EXAM (2023/2024
QUESTIONS AND ANSWERS WITH RATIONELS.)
1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the
nausea and vomiting. The nurse tells the client to:
A. Eat foods high in calories and fat
B. Lie down for at least 20 minutes after meals
C. Eat carbohydrates such as cereals, rice, and pasta Correct
D. Consume primarily soups and liquids at mealtimes
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta
provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and
other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting
upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong
odors should be eliminated from the diet, because food smells often incite nausea.
A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent
eclampsia. Which finding indicates to the nurse that the medication is effective?
E. Clonus is present. Incorrect
F. Magnesium level is 10 mg/dL.
G. Deep tendon reflexes are absent.
H. The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48
hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the
client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of
the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure
activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic
magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of
magnesium toxicity. The nurse immediately prepares for the administration of:
I. Vitamin K
J. Protamine sulfate Incorrect
K. Calcium gluconate Correct
L. Naloxone hydrochloride
Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of
magnesium at the neuromuscular junction. It should be readily available whenever magnesium is
administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral
anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of
,hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat
opioid-induced respiratory depression.
A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the
client is the best source of folic acid?
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green
leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is
high in calcium. Chicken and steak are high in protein.
A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about
treatment of the condition. The nurse tells the mother to:
Q. Avoid the use of shampoo on the infant’s scalp Incorrect
R. Apply oil to the affected area on the infant’s scalp Correct
S. Wash the infant’s scalp daily, using only tepid water
T. Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is
characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior
fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g.,
mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb
before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain
that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to
remove all soap, which could cause irritation. A nurse is monitoring a client who was given an epidural opioid
for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse
first:
U. Notifies the registered nurse
V. Documents the findings
W. Instructs the client to take several deep breaths Correct
X. Administers 100% oxygen by way of face mask Incorrect
Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory
status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep
breaths to increase the level. Although the finding would be documented, action is required to increase the
oxygen saturation level. It is not necessary to contact the registered nurse. If the deep breaths fail to increase
the oxygen saturation level, the registered nurse is notified and may prescribe oxygen.
,A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is
experiencing a white vaginal discharge. The nurse tells the client:
Y. To perform a vaginal douche
Z. To come to the clinic for a checkup Incorrect
AA. That this is an indication of an infection
AB. That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small
particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood
decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this
stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and
the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains
leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until
the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during
the postpartum course, and no intervention is required, so the other options are incorrect.
A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not
immune to rubella. The nurse tells the client that:
AC. A rubella vaccine must be administered immediately Incorrect
AD. A rubella vaccine must be administered after childbirth Correct
AE. She will not contract rubella if she is exposed to the disease
AF. She does not need to be concerned about being exposed to rubella
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether
she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is
offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a
live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the
mother were to become pregnant soon after it was administered. Administering a rubella vaccine
immediately places the fetus at risk. Telling the client that she does not need to be concerned about being
exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does
exist.
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s
temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:
AG. Notify the registered nurse
AH. Recheck the temperature in 1 hour Incorrect
AI. Encourage the intake of oral fluids Correct
AJ. Tell the client that antibiotics will be prescribed
, Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the
result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer
than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the registered nurse.
Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage
the intake of oral fluids.
A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is
boggy. The nurse massages the fundus, and then presses to expel clots from the uterus.
To prevent uterine inversion during this procedure, the nurse: AK. Has
the client void before the uterine assessment
AL. Tells the woman to bear down during fundal message
AM. Simultaneously provides pressure over the lower uterine segment Correct
AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from
the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower
uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing
pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine
assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs
fundal message and asking the client to take slow, deep breaths during fundal assessment also will not
prevent uterine inversion.
A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the
client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the
first action and the number 5 to the last.
Incorrect
A. Assessing the client’s fundus
B. Checking the client’s vital signs
C. Changing the client’s peripads
D. Contacting the physician
E. Documenting the findings
The correct order is:
F. Assessing the client’s fundus
G. Checking the client’s vital signs
H. Contacting the physician
I. Changing the client’s peripads
J. Documenting the findings
Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate
attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the
result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has
compromised the client’s condition. Next the nurse would contact the physician and report the bleeding,
fundal height and condition, and vital signs. After contacting the physician the nurse would attend to the
QUESTIONS AND ANSWERS WITH RATIONELS.)
1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the
nausea and vomiting. The nurse tells the client to:
A. Eat foods high in calories and fat
B. Lie down for at least 20 minutes after meals
C. Eat carbohydrates such as cereals, rice, and pasta Correct
D. Consume primarily soups and liquids at mealtimes
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta
provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and
other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting
upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong
odors should be eliminated from the diet, because food smells often incite nausea.
A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent
eclampsia. Which finding indicates to the nurse that the medication is effective?
E. Clonus is present. Incorrect
F. Magnesium level is 10 mg/dL.
G. Deep tendon reflexes are absent.
H. The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48
hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the
client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of
the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure
activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic
magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of
magnesium toxicity. The nurse immediately prepares for the administration of:
I. Vitamin K
J. Protamine sulfate Incorrect
K. Calcium gluconate Correct
L. Naloxone hydrochloride
Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of
magnesium at the neuromuscular junction. It should be readily available whenever magnesium is
administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral
anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of
,hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat
opioid-induced respiratory depression.
A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the
client is the best source of folic acid?
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green
leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is
high in calcium. Chicken and steak are high in protein.
A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about
treatment of the condition. The nurse tells the mother to:
Q. Avoid the use of shampoo on the infant’s scalp Incorrect
R. Apply oil to the affected area on the infant’s scalp Correct
S. Wash the infant’s scalp daily, using only tepid water
T. Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is
characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior
fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g.,
mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb
before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain
that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to
remove all soap, which could cause irritation. A nurse is monitoring a client who was given an epidural opioid
for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse
first:
U. Notifies the registered nurse
V. Documents the findings
W. Instructs the client to take several deep breaths Correct
X. Administers 100% oxygen by way of face mask Incorrect
Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory
status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep
breaths to increase the level. Although the finding would be documented, action is required to increase the
oxygen saturation level. It is not necessary to contact the registered nurse. If the deep breaths fail to increase
the oxygen saturation level, the registered nurse is notified and may prescribe oxygen.
,A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is
experiencing a white vaginal discharge. The nurse tells the client:
Y. To perform a vaginal douche
Z. To come to the clinic for a checkup Incorrect
AA. That this is an indication of an infection
AB. That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small
particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood
decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this
stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and
the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains
leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until
the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during
the postpartum course, and no intervention is required, so the other options are incorrect.
A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not
immune to rubella. The nurse tells the client that:
AC. A rubella vaccine must be administered immediately Incorrect
AD. A rubella vaccine must be administered after childbirth Correct
AE. She will not contract rubella if she is exposed to the disease
AF. She does not need to be concerned about being exposed to rubella
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether
she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is
offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a
live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the
mother were to become pregnant soon after it was administered. Administering a rubella vaccine
immediately places the fetus at risk. Telling the client that she does not need to be concerned about being
exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does
exist.
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s
temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:
AG. Notify the registered nurse
AH. Recheck the temperature in 1 hour Incorrect
AI. Encourage the intake of oral fluids Correct
AJ. Tell the client that antibiotics will be prescribed
, Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the
result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer
than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the registered nurse.
Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage
the intake of oral fluids.
A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is
boggy. The nurse massages the fundus, and then presses to expel clots from the uterus.
To prevent uterine inversion during this procedure, the nurse: AK. Has
the client void before the uterine assessment
AL. Tells the woman to bear down during fundal message
AM. Simultaneously provides pressure over the lower uterine segment Correct
AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from
the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower
uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing
pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine
assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs
fundal message and asking the client to take slow, deep breaths during fundal assessment also will not
prevent uterine inversion.
A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the
client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the
first action and the number 5 to the last.
Incorrect
A. Assessing the client’s fundus
B. Checking the client’s vital signs
C. Changing the client’s peripads
D. Contacting the physician
E. Documenting the findings
The correct order is:
F. Assessing the client’s fundus
G. Checking the client’s vital signs
H. Contacting the physician
I. Changing the client’s peripads
J. Documenting the findings
Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate
attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the
result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has
compromised the client’s condition. Next the nurse would contact the physician and report the bleeding,
fundal height and condition, and vital signs. After contacting the physician the nurse would attend to the
