ATI RN COMPREHENSIVE EXIT RETAKE EXAM
REVISED 2024 ACTUAL EXAM COMPLETE 180
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+.
Following discharge teaching, a male client with duodenal ulcer tells
the nurse the he will drink plenty of dairy products, such as milk, to
help coat and protect his ulcer. What is the best follow-up action by
the nurse?
a. Remind the client that it is also important to switch to decaffeinated
coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk
and cream.
d. Reinforce this teaching by asking the client to list a dairy food that
he might select. - ANSWER>>> Review with the client the need to
avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to
evaluate his blood pressure (BP). His BP is 158/106 and he admits
that he has not been taking the prescribed medication because the
drugs make him "feel bad". In explaining the need for hypertension
control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
,c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage - ANSWER>>> Stroke
secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. The
client is supine and the UAP is placing soft pillows along the side rails.
What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the
client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
c. Assume responsibility for placing the pillows while the UAP
completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side
lying position. - ANSWER>>> Instruct the UAP to obtain soft blankets
to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with
soft blankest because the use of pillows could result in suffocation and
would need to be removed at the onset of the seizure. The nurse can
delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment finding
requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating. - ANSWER>>> Describes life
without purpose
,Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal thinking
in adolescents and young adults with major depressive disorder. B, C
and D are side effects
A 60-year-old female client with a positive family history of ovarian
cancer has developed an abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's
teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed. -
ANSWER>>> Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse
to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site. - ANSWER>>>
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
In assessing an adult client with a partial rebreather mask, the nurse
notes that the oxygen reservoir bag does not deflate completely during
, inspiration and the client's respiratory rate is 14 breaths / minute.
What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data - ANSWER>>> Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes. - ANSWER>>>
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory
apnea that should be assessed first.
During a home visit, the nurse observed an elderly client with diabetes
slip and fall. What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level - ANSWER>>> Check the client for
lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess
for the possibility of injuries and provide first aid as needed
REVISED 2024 ACTUAL EXAM COMPLETE 180
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+.
Following discharge teaching, a male client with duodenal ulcer tells
the nurse the he will drink plenty of dairy products, such as milk, to
help coat and protect his ulcer. What is the best follow-up action by
the nurse?
a. Remind the client that it is also important to switch to decaffeinated
coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk
and cream.
d. Reinforce this teaching by asking the client to list a dairy food that
he might select. - ANSWER>>> Review with the client the need to
avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
and should be avoided.
A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to
evaluate his blood pressure (BP). His BP is 158/106 and he admits
that he has not been taking the prescribed medication because the
drugs make him "feel bad". In explaining the need for hypertension
control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
,c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage - ANSWER>>> Stroke
secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder. The
client is supine and the UAP is placing soft pillows along the side rails.
What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to protect the
client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
c. Assume responsibility for placing the pillows while the UAP
completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side
lying position. - ANSWER>>> Instruct the UAP to obtain soft blankets
to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with
soft blankest because the use of pillows could result in suffocation and
would need to be removed at the onset of the seizure. The nurse can
delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment finding
requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating. - ANSWER>>> Describes life
without purpose
,Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal thinking
in adolescents and young adults with major depressive disorder. B, C
and D are side effects
A 60-year-old female client with a positive family history of ovarian
cancer has developed an abdominal mass and is being evaluated for
possible ovarian cancer. Her Papanicolau (Pap) smear results are
negative. What information should the nurse include in the client's
teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed. -
ANSWER>>> Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse
to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site. - ANSWER>>>
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
In assessing an adult client with a partial rebreather mask, the nurse
notes that the oxygen reservoir bag does not deflate completely during
, inspiration and the client's respiratory rate is 14 breaths / minute.
What action should the nurse implement
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data - ANSWER>>> Document the
assessment data
Rational: reservoir bag should not deflate completely during inspiration
and the client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes. - ANSWER>>>
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory
apnea that should be assessed first.
During a home visit, the nurse observed an elderly client with diabetes
slip and fall. What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level - ANSWER>>> Check the client for
lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess
for the possibility of injuries and provide first aid as needed
