ATI Comprehensive Exam
Enteral Feeding - NG Tube - Answers -Keep HOB elevated to 45degrees for 1 hour
after feedings.
Avoid adding dye to feedings.
Flush NG tube with 20 mL of Tap water.
Inject 10-30 mL of Air into NG tube Before checking residual to clear the tube of any
feeding.
Food High in Vitamin A - Answers -1 Medium Raw Carrot
also: spinach, squash, cantaloupe
RN delegates to LPN - Answers -Insertion of NG Tube
NOT: Administering RBCs!
RN delegates to UAP - Answers -Collection of Stool Specimen
Preparation of a pt's post-op bed
TPN - Stopped, waiting for new pump - Answers -Administer D10W to prevent
Hypoglycemia from the stopped TPN infusion
A nurse is assessing a pt who has schizophrenia and is taking Chlorpromazine.
Which of the following findings is the priority for the nurse to report to the provider? -
Answers -Temp of 103 F !!
Neuroleptic Malignant Syndrome, potentially life-threatening AE of Chlorpromazine.
Non-urgent:
HA
Constipation
Vomiting
Ear drops Administration (School-Age Child) - Answers -Pull the pinna UPWARD and
BACK
(children older than 3 years)
Warm to room temperature
Massage the tragus of the ear gently
, Lie on the unaffected side for a few minutes after administration.
Autonomic Dysreflexia S/S - Answers -Headache
Facial Flushing
Nasal Congestion
CN II Deficit (Nurse Care) - Answers -Clear objects from the pt's walking area.
Visually impaired.
McBurney's point - Answers -Pain in RLQ with appendicitis
Interventions for Thrombocytopenia - Answers -Avoid Venipunctures when possible.
(Prevent the risk for bleeding)
A nurse in the delivery room is caring for a newborn immediately after birth.
Which of the following actions should the nurse take FIRST? - Answers -A. Dry the
newborn
B. Assign the first Apgar score.
C. Place ID bracelet on the newborn.
D. Obtain the newborn's weight.
ANS A: Dry the newborn.
Risk is Cold Stress!
Normal Temperature - Newborn - Answers -(Axillary) 97.7 - 100 F
Stage 2 Pressure Ulcer Characteristics - Answers -Partial-Thickness Skin Loss
Blister Formation
Stage 3 Pressure Ulcer Characteristics - Answers -Visible SubQ Tissue
Stage 4 Pressure Ulcer Characteristics - Answers -Tendon Exposure
Muscle Damage
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following
actions should the nurse take? - Answers -Initiate oral Rehydration therapy for the
toddler.
Rationale: Diarrhea causes dehydration, which results in fluid volume deficit.
A nurse is caring for a client who had a recent stroke.
Prior to transferring the client to the bedside commode, which of the following actions
should the nurse take first? - Answers -Assess the client for functional limitations.
Enteral Feeding - NG Tube - Answers -Keep HOB elevated to 45degrees for 1 hour
after feedings.
Avoid adding dye to feedings.
Flush NG tube with 20 mL of Tap water.
Inject 10-30 mL of Air into NG tube Before checking residual to clear the tube of any
feeding.
Food High in Vitamin A - Answers -1 Medium Raw Carrot
also: spinach, squash, cantaloupe
RN delegates to LPN - Answers -Insertion of NG Tube
NOT: Administering RBCs!
RN delegates to UAP - Answers -Collection of Stool Specimen
Preparation of a pt's post-op bed
TPN - Stopped, waiting for new pump - Answers -Administer D10W to prevent
Hypoglycemia from the stopped TPN infusion
A nurse is assessing a pt who has schizophrenia and is taking Chlorpromazine.
Which of the following findings is the priority for the nurse to report to the provider? -
Answers -Temp of 103 F !!
Neuroleptic Malignant Syndrome, potentially life-threatening AE of Chlorpromazine.
Non-urgent:
HA
Constipation
Vomiting
Ear drops Administration (School-Age Child) - Answers -Pull the pinna UPWARD and
BACK
(children older than 3 years)
Warm to room temperature
Massage the tragus of the ear gently
, Lie on the unaffected side for a few minutes after administration.
Autonomic Dysreflexia S/S - Answers -Headache
Facial Flushing
Nasal Congestion
CN II Deficit (Nurse Care) - Answers -Clear objects from the pt's walking area.
Visually impaired.
McBurney's point - Answers -Pain in RLQ with appendicitis
Interventions for Thrombocytopenia - Answers -Avoid Venipunctures when possible.
(Prevent the risk for bleeding)
A nurse in the delivery room is caring for a newborn immediately after birth.
Which of the following actions should the nurse take FIRST? - Answers -A. Dry the
newborn
B. Assign the first Apgar score.
C. Place ID bracelet on the newborn.
D. Obtain the newborn's weight.
ANS A: Dry the newborn.
Risk is Cold Stress!
Normal Temperature - Newborn - Answers -(Axillary) 97.7 - 100 F
Stage 2 Pressure Ulcer Characteristics - Answers -Partial-Thickness Skin Loss
Blister Formation
Stage 3 Pressure Ulcer Characteristics - Answers -Visible SubQ Tissue
Stage 4 Pressure Ulcer Characteristics - Answers -Tendon Exposure
Muscle Damage
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following
actions should the nurse take? - Answers -Initiate oral Rehydration therapy for the
toddler.
Rationale: Diarrhea causes dehydration, which results in fluid volume deficit.
A nurse is caring for a client who had a recent stroke.
Prior to transferring the client to the bedside commode, which of the following actions
should the nurse take first? - Answers -Assess the client for functional limitations.
