ATI Comprehensive B Questions and
Answers Graded A+
Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?
✔✔Ask another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT
98 seconds and INR 1.8 ✔✔Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which
indicates the client has a detached retina ✔✔Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to
report to provider ✔✔Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take ✔✔Auscultate the apical pulse
and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the
stool ✔✔Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine ✔✔Broccoli, Yogurt, Cream Cheese
,Nurse administers incorrect dose of medication. Which facts related to incident report should the
nurse document in the client's medical record? ✔✔Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first?
✔✔A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden
relief of pain. Can indicate peritonitis from a ruptured appendix.
Community health nurse providing teaching on home safety for older adults ✔✔Have grab bars
installed around your bathtub and toilet.
School age child with scald burns on both hands and wrists suspected abuse ✔✔Contact child
protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion
✔✔Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational ✔✔I will wear a supportive bra
overnight
Discharge instructions to client to received home oxygen therapy ✔✔Wear clothing made with
cotton fabrics while oxygen is in use.
, Preparing an educational session about advocacy to a group of nurses ✔✔Advocacy is a leadership
role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output ✔✔Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis ✔✔Infuse IV fluids
Client teaching about the basal body temp method for birth control ✔✔Your body temperature
might decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to
locate family to obtain consent ✔✔Proceed with provision of medical care
Client who has fluid volume overload. Which tasks can nurse delegate to UAP ✔✔Measure the
client's daily weight
Checking for Chvostek's sign ✔✔The nurse should assess for a Chvostek's sign by tapping the
client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive
finding that indicates hypocalcemia.
Answers Graded A+
Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?
✔✔Ask another nurse to witness the disposal of the new patch.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT
98 seconds and INR 1.8 ✔✔Withhold the heparin infusion
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which
indicates the client has a detached retina ✔✔Floating dark spots
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to
report to provider ✔✔Irritability when being held. signifies increased ICP
Assessing a newborn heart rate follow actions the nurse should take ✔✔Auscultate the apical pulse
and count beats for at least 1 min.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the
stool ✔✔Insert a lubricated gloved finger and advance along the rectal wall.
Dietary teaching for a new prescription of phenelzine ✔✔Broccoli, Yogurt, Cream Cheese
,Nurse administers incorrect dose of medication. Which facts related to incident report should the
nurse document in the client's medical record? ✔✔Time the medication was given
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first?
✔✔A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden
relief of pain. Can indicate peritonitis from a ruptured appendix.
Community health nurse providing teaching on home safety for older adults ✔✔Have grab bars
installed around your bathtub and toilet.
School age child with scald burns on both hands and wrists suspected abuse ✔✔Contact child
protective services.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion
✔✔Explore the client's reasons fro refusing the treatment
Discussing common prenatal discomfort 20 weeks gestational ✔✔I will wear a supportive bra
overnight
Discharge instructions to client to received home oxygen therapy ✔✔Wear clothing made with
cotton fabrics while oxygen is in use.
, Preparing an educational session about advocacy to a group of nurses ✔✔Advocacy is a leadership
role that helps others to self actualize
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output ✔✔Irrigate the catheter with 0.9% sodium chloride irrigation
Child with sickle cell anemia and is having a vaso-occlusive crisis ✔✔Infuse IV fluids
Client teaching about the basal body temp method for birth control ✔✔Your body temperature
might decrease slightly just prior to ovulation
Caring for a client who is unconscious and requires emergency medical procedures. Unable to
locate family to obtain consent ✔✔Proceed with provision of medical care
Client who has fluid volume overload. Which tasks can nurse delegate to UAP ✔✔Measure the
client's daily weight
Checking for Chvostek's sign ✔✔The nurse should assess for a Chvostek's sign by tapping the
client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive
finding that indicates hypocalcemia.
