ATI Comprehensive Exit Retake Exam 2025 Questions and Answers With Rationales |Latest & Graded A+

ATI Comprehensive Exit Retake Exam 2025 Questions and Answers |Latest & Graded A+ ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? ◦ Options: ▪ a. "You don't have to go through with the treatment." ▪ b. "Most people who have this procedure feel better following the treatment." ▪ c. "It's okay to be nervous before this treatment." ▪ d. "Your doctor wouldn't have ordered this treatment unless it was necessary." ◦ Correct Answer: a. "You don't have to go through with the treatment." ◦ Rationale: Informed consent includes the right to refuse treatment at any time. The nurse should respect the client’s autonomy and reinforce their decisionmaking power. Options b, c, and d may pressure or dismiss the client’s concerns. The nurse should document the refusal and notify the provider. 2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device. Which of the following actions should the nurse take first? ◦ Options: ▪ a. Report the defect to the equipment maintenance staff. ▪ b. Ensure the device inspection sticker is current. ▪ c. Remove the device from the room. ▪ d. Initiate a requisition for a replacement CPM device. ◦ Correct Answer: c. Remove the device from the room. ◦ Rationale: A frayed cord poses an immediate risk of electrical shock or fire. Removing the device eliminates the hazard, prioritizing safety. Subsequent actions include reporting the defect and requesting a replacement. Checking the inspection sticker does not address the immediate danger. 3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Document administration of the medication upon removal from the medication dispensing system. ▪ b. Withhold the medication if the client does not appear to be in pain. ▪ c. Count the current number of unit doses available in the medication dispensing system. ▪ d. Withhold the medication if the client has a fever. ◦ Correct Answer: c. Count the current number of unit doses available in the medication dispensing system. ◦ Rationale: Hydromorphone is a controlled substance, requiring accurate inventory tracking to prevent diversion. Counting doses ensures accountability. Documenting occurs after administration, and withholding based on appearance or fever is inappropriate without provider guidance, as pain is subjective. 4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? ◦ Options: ▪ a. Type 2 DM and a blood glucose of 250 mg/dL. ▪ b. Pneumonia with a productive cough and a fever of 38.8°C (101.8°F). ▪ c. 2 hr. post cast placement and has 2+ pitting edema and pallor. ▪ d. First-degree heart block and a heart rate of 62/min. ◦ Correct Answer: c. 2 hr. post cast placement and has 2+ pitting edema and pallor. ◦ Rationale: Edema and pallor post-cast placement suggest compartment syndrome, a medical emergency requiring immediate intervention to prevent tissue damage. Hyperglycemia, pneumonia, and first-degree heart block are less urgent. The nurse should assess the “6 Ps” (pain, pallor, pulselessness, paresthesia, paralysis, pressure) and notify the provider. 5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? ◦ Options: ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ a. "I will limit my alcohol use to one drink daily while taking disulfiram." ▪ b. "I will avoid foods containing tyramine while taking fluoxetine." ▪ c. "I will take the sustained-release methylphenidate every morning." ▪ d. "I will take my lithium on an empty stomach." ◦ Correct Answer: c. "I will take the sustained-release methylphenidate every morning." ◦ Rationale: Sustained-release methylphenidate is taken in the morning to manage ADHD symptoms and avoid sleep disturbances. Disulfiram requires complete alcohol avoidance, tyramine restrictions apply to MAOIs (not fluoxetine), and lithium is taken with food to reduce GI distress. 6. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit] ◦ Options: ▪ a. Administer Zofran to the client for nausea. ▪ b. Implement seizure precautions for the client. ▪ c. Encourage the client to verbalize feelings. ▪ d. Obtain the client’s weight. ◦ Correct Answer: c. Encourage the client to verbalize feelings. ◦ Rationale: In major depressive disorder, assessing mental status and suicide risk is the priority. Encouraging verbalization helps evaluate the client’s emotional state. Without the exhibit, this is the most client-centered action. Nausea, seizures, or weight are secondary unless indicated by specific symptoms. 7. A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following should the nurse expect? ◦ Options: ▪ a. Suspicious of others. ▪ b. Exhibits separation anxiety. ▪ c. Ritualistic behavior. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ d. Preoccupied with aging. ◦ Correct Answer: None listed (assumed: grandiose behavior or need for admiration, based on DSM-5 criteria). ◦ Rationale: Narcissistic personality disorder is characterized by grandiosity, need for admiration, and lack of empathy. None of the options directly align, but suspicion (paranoid), separation anxiety (dependent), ritualistic behavior (OCD), and preoccupation with aging are not typical. The nurse should expect behaviors like entitlement or self-centeredness. 8. Drug Calc: Client weighs 99 lb. Prescribed diet of 1.5 g protein/kg/day. How many grams of protein per day should the nurse include in the client’s dietary plan? ◦ Correct Answer: 67.5 g protein/day. ◦ Rationale: Convert weight to kilograms: 99 lb ÷ 2.2 = 45 kg. Calculate protein: 45 kg × 1.5 g/kg = 67.5 g. The nurse should ensure the dietary plan includes 67.5 g of protein daily, adjusting for client preferences and restrictions. 9. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should the nurse take first to manage her time effectively? ◦ Options: ▪ a. Develop an hourly time frame for tasks. ▪ b. Schedule daily activities. ▪ c. Determine goals of the day. ▪ d. Delegate tasks to the AP. ◦ Correct Answer: c. Determine goals of the day. ◦ Rationale: Establishing goals prioritizes client care needs and guides task delegation and scheduling. This step ensures efficient time management. Developing a timeframe, scheduling, or delegating follows goal-setting. 10. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? ◦ Options: ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ a. Restrict the client’s total fluid intake to 250 mL/hr. ▪ b. Measure the client’s urine output every hour. ▪ c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium gluconate). ▪ d. Monitor the FHR via Doppler every 30 min. ◦ Correct Answer: b. Measure the client’s urine output every hour. ◦ Rationale: Magnesium sulfate can cause renal toxicity. Monitoring urine output (at least 30 mL/hr) ensures adequate renal function. Protamine is the antidote for heparin, not magnesium (calcium gluconate is correct). Fluid restriction and frequent FHR monitoring are not primary actions. 11. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? ◦ Options: ▪ a. Infected laceration. ▪ b. Stage II pressure ulcer. ▪ c. Approximated surgical incision. ▪ d. Partial-thickness burn. ◦ Correct Answer: c. Approximated surgical incision. ◦ Rationale: Primary intention healing occurs when wound edges are closely approximated, as in a clean surgical incision, with minimal tissue loss. Infected lacerations, pressure ulcers, and burns typically heal by secondary or tertiary intention due to tissue damage or infection. 12. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? ◦ Options: ▪ a. Client taking clozapine to treat schizophrenia and reports sore throat. ▪ b. Client has OCD and is upset about a change in daily routine. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ c. Client has narcissistic personality disorder and is mocking others during group therapy. ▪ d. Client who has depressive disorder and requires assistance with ADLs. ◦ Correct Answer: a. Client taking clozapine to treat schizophrenia and reports sore throat. ◦ Rationale: A sore throat in a client taking clozapine may indicate agranulocytosis, a life-threatening adverse effect. Immediate assessment and a CBC are needed. The other clients’ needs are less urgent, as they do not indicate immediate harm. 13. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? ◦ Options: ▪ a. An angiocatheter. ▪ b. A butterfly needle. ▪ c. A noncoring needle. ▪ d. A 25-gauge needle. ◦ Correct Answer: c. A noncoring needle. ◦ Rationale: A noncoring (Huber) needle is designed for implanted venous access ports to prevent damage to the port’s septum, ensuring safe access. Other needles may cause coring or leakage, compromising the port’s integrity. 14. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? ◦ Options: ▪ a. PT and INR. ▪ b. 12-lead ECG. ▪ c. Chest X-ray. ▪ d. Serum potassium. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Correct Answer: b. 12-lead ECG. ◦ Rationale: Chest pain described as heavy pressure suggests a possible cardiac event (e.g., myocardial infarction). A 12-lead ECG is the priority to assess for ischemia or arrhythmias. Other tests may follow based on ECG findings. 15. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse ask the parent to determine if the child is exhibiting typical developmental expectations? ◦ Options: ▪ a. “Can your child draw a stick figure?” ▪ b. “Can your child catch and throw a small ball?” ▪ c. “Can your child ride a tricycle?” ▪ d. “Can your child name five colors?” ◦ Correct Answer: c. “Can your child ride a tricycle?” ◦ Rationale: At age 3, children typically develop gross motor skills like riding a tricycle. Drawing a stick figure (age 4–5), catching/throwing a ball (age 4), or naming five colors (age 4–5) are milestones for older children. 16. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? ◦ Options: ▪ a. Measure the fundal height to determine the placement of the ultrasound stethoscope. ▪ b. Perform Leopold maneuvers prior to auscultating the FHR. ▪ c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR. ▪ d. Place the client in a side-lying position prior to assessing the FHR. ◦ Correct Answer: c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR. ◦ Rationale: At 12 weeks, the fetus is low in the pelvis, so the Doppler is placed above the symphysis pubis to detect the FHR. Fundal height and Leopold ATI Comprehensive Exit Retake Exam 2025 Questions and Answers maneuvers are used later in pregnancy, and side-lying is not necessary for this assessment. 17. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? ◦ Options: ▪ a. There is a loop of tubing below the drainage system. ▪ b. The system is working properly. ▪ c. The lung has re-expanded. ▪ d. The tubing is partially obstructed by clots. ◦ Correct Answer: b. The system is working properly. ◦ Rationale: Tidaling (fluctuations in the water seal chamber with respiration) indicates a patent system and negative pressure in the pleural space. Absence of tidaling may suggest lung re-expansion or obstruction, but tidaling itself is normal. 18. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? ◦ Options: ▪ a. A client who is receiving heparin for DVT. ▪ b. A client who is 1 day postoperative following a vertebroplasty. ▪ c. A client who has COPD and a respiratory rate of 44/min. ▪ d. A client who has cancer with a sealed implant for radiation therapy. ◦ Correct Answer: b. A client who is 1 day postoperative following a vertebroplasty. ◦ Rationale: Vertebroplasty is a minimally invasive procedure with a short recovery. A stable client 1 day post-op is suitable for discharge. Clients with DVT, severe COPD, or radiation implants require ongoing hospital care due to risk or complexity. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 19. A nurse is caring for a client who has ESRD. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure? ◦ Options: ▪ a. Osteoarthritis. ▪ b. HTN. ▪ c. Amputation. ▪ d. Primary glaucoma. ◦ Correct Answer: b. HTN. ◦ Rationale: Hypertension is a contraindication for living kidney donation due to the risk of renal complications post-donation. Osteoarthritis, amputation, and glaucoma do not typically affect donor eligibility unless severe. 20. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) ◦ Options: ▪ a. Foul perineal odor. ▪ b. Fundus displaced to the right. ▪ c. Lochia serosa. ▪ d. Fundus 4 cm (1.6 in) below the umbilicus. ▪ e. Postpartum chill. ◦ Correct Answer: c. Lochia serosa, d. Fundus 4 cm (1.6 in) below the umbilicus. ◦ Rationale: At 4 days postpartum, lochia serosa (pinkish discharge) and a fundus 4 cm below the umbilicus are expected as the uterus involutes. Foul odor suggests infection, a displaced fundus indicates a full bladder or abnormality, and chills are not typical beyond the immediate postpartum period. 21. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Perform the procedure twice a day. ▪ b. Hold hand to perform percussions on the child. ▪ c. Administer a bronchodilator after the procedure. ▪ d. Perform the procedure prior to meals. ◦ Correct Answer: d. Perform the procedure prior to meals. ◦ Rationale: Postural drainage is best performed before meals to avoid nausea or vomiting. It should be done 2–3 times daily, using cupped hands for percussion, and bronchodilators are typically given before to open airways. 22. A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take? ◦ Options: ▪ a. Ensure that the client checks the gauge weekly. ▪ b. Store the oxygen tank wrench in a locked cabinet. ▪ c. Have the client store smaller tanks under his bed. ▪ d. Place the oxygen tank away from curtains or drapes. ◦ Correct Answer: d. Place the oxygen tank away from curtains or drapes. ◦ Rationale: Oxygen is flammable, and keeping tanks away from combustible materials like curtains reduces fire risk. Storing tanks under the bed or locking the wrench impedes access, and weekly gauge checks are insufficient. 23. Location of crackles [IMAGE] ◦ Correct Answer: Not applicable (image-based question). ◦ Rationale: Crackles are typically heard in the lower lung fields, indicating fluid in the alveoli (e.g., pneumonia, heart failure). Without the image, the nurse should assess lung bases bilaterally using a stethoscope. 24. A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Implement seizure precautions. ▪ b. Place the client in high-Fowler’s position. ▪ c. Perform ROM exercises once per shift. ▪ d. Monitor the client for hypoglycemia. ◦ Correct Answer: a. Implement seizure precautions. ◦ Rationale: Bacterial meningitis can cause increased intracranial pressure, increasing seizure risk. Seizure precautions (e.g., padded rails, suction ready) are critical. High-Fowler’s may worsen headache, ROM is not a priority, and hypoglycemia is not a primary concern. 25. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? ◦ Options: ▪ a. Na 142 mEq/L. ▪ b. Blood glucose 80 mg/dL. ▪ c. K 3.3 mEq/L. ▪ d. PT 11.5 seconds. ◦ Correct Answer: c. K 3.3 mEq/L. ◦ Rationale: A potassium level of 3.3 mEq/L (hypokalemia) increases the risk of arrhythmias, especially during surgery. The other values are within normal limits (Na 135–145, glucose 70–110, PT 11–13.5). 26. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? ◦ Options: ▪ a. Reset the vacuum by compressing the container. ▪ b. Secure the drain to the bedding. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ c. Position the affected extremity below the level of the client’s heart. ▪ d. Maintain the client in a supine position for the first 24 hr. ◦ Correct Answer: a. Reset the vacuum by compressing the container. ◦ Rationale: Closed-suction drains (e.g., Jackson-Pratt) require compression to maintain suction and promote drainage. Securing to bedding risks dislodgement, elevating the extremity reduces edema, and semi-Fowler’s is preferred over supine. 27. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? ◦ Options: ▪ a. DM and HbA1c of 5.2%. ▪ b. Leukemia and platelet level of 95,000/mm³. ▪ c. Received IV Lasix and K of 3.6 mEq/L. ▪ d. Hepatitis B and total bilirubin of 1.2 mg/dL. ◦ Correct Answer: b. Leukemia and platelet level of 95,000/mm³. ◦ Rationale: A platelet count of 95,000/mm³ indicates thrombocytopenia, increasing bleeding risk, especially in leukemia. This client requires immediate assessment for bleeding. The other findings are stable or less urgent. 28. A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? ◦ Options: ▪ a. Minimize noise in the newborn’s environment. ▪ b. Swaddle the newborn with his legs extended. ▪ c. Administer naloxone to the newborn. ▪ d. Maintain eye contact with the newborn during feedings. ◦ Correct Answer: a. Minimize noise in the newborn’s environment. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Rationale: Neonatal abstinence syndrome causes irritability and overstimulation. A quiet environment reduces stress. Swaddling should flex the legs, naloxone is not routine, and eye contact may overstimulate. 29. Nutritional teaching for an adult client who has a seizure disorder and a new prescription for phenytoin. Which of the following instructions by the nurse is appropriate? ◦ Options: ▪ a. “You should expect a change in the color of your stool while taking this medication.” ▪ b. “Increase your intake of vitamin D while taking this medication.” ▪ c. “Plan to take this medication with antacids.” ▪ d. “Limit foods that contain folic acid while taking this medication.” ◦ Correct Answer: b. “Increase your intake of vitamin D while taking this medication.” ◦ Rationale: Phenytoin can decrease vitamin D and calcium absorption, increasing osteoporosis risk. Clients should increase vitamin D intake. Antacids reduce phenytoin absorption, and folic acid may be supplemented, not limited. 30. A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? ◦ Options: ▪ a. Presence of bloody show. ▪ b. Contraction intensity increased by ambulation. ▪ c. Slow change in dilation and effacement. ▪ d. Intermittent, painless contractions. ◦ Correct Answer: d. Intermittent, painless contractions. ◦ Rationale: False labor (Braxton Hicks) involves irregular, painless contractions that do not cause cervical change. Bloody show, increased intensity with ambulation, and slow cervical change suggest true labor. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 31. A nurse is caring for a client who has C. diff. Which of the following actions should the nurse take? (SATA) ◦ Options: ▪ a. Wash hands with alcohol-based. ▪ b. Wear N95. ▪ c. Remove thermometer from client’s room for use on another client. ▪ d. Change gloves after contact with infectious material. ▪ e. Wear a gown when providing care. ◦ Correct Answer: d. Change gloves after contact with infectious material, e. Wear a gown when providing care. ◦ Rationale: C. diff requires contact precautions, including gowns and gloves, with glove changes after contact with infectious material. Hand washing with soap and water (not alcohol) is needed, N95 is for airborne precautions, and thermometers should be dedicated to the client. 32. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? ◦ Options: ▪ a. DM and HbA1c of 6.8%. ▪ b. Hip fracture and a new onset of tachypnea. ▪ c. Epidural analgesia and weakness in lower extremities. ▪ d. Sinus arrhythmia and is receiving cardiac monitoring. ◦ Correct Answer: b. Hip fracture and a new onset of tachypnea. ◦ Rationale: Tachypnea in a client with a hip fracture suggests a pulmonary embolism, a life-threatening complication. Immediate assessment is needed. The other findings are less urgent or expected. 33. Nurse accidentally punctures IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Phenytoin. ▪ b. Doxorubicin hydrochloride. ▪ c. Metronidazole. ▪ d. Ampicillin sodium. ◦ Correct Answer: b. Doxorubicin hydrochloride. ◦ Rationale: Doxorubicin is a chemotherapeutic agent classified as a biohazard. Spills require specific handling procedures to prevent exposure. The other medications are not biohazardous. 34. Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? ◦ Options: ▪ a. Respiratory rate 22/min. ▪ b. Hgb 8.7 g/dL. ▪ c. 2+ pitting edema of the ankles. ▪ d. Creatinine 2.3 mg/dL. ◦ Correct Answer: d. Creatinine 2.3 mg/dL. ◦ Rationale: Gentamicin is nephrotoxic, and elevated creatinine indicates kidney damage. The other findings are not directly related to gentamicin’s adverse effects. 35. Which of the following clients should the nurse recommend referral to a dietitian? ◦ Options: ▪ a. Older adult who has BMI of 24. ▪ b. Client with albumin of 3.7 g/dL. ▪ c. Older adult who has presbyopia. ▪ d. Client who has a nonhealing leg ulcer. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Correct Answer: d. Client who has a nonhealing leg ulcer. ◦ Rationale: Nonhealing wounds require nutritional optimization (e.g., protein, vitamins) to promote healing, warranting a dietitian referral. A BMI of 24 and albumin of 3.7 g/dL are normal, and presbyopia is unrelated to nutrition. 36. Support group for clients whose family have committed suicide. Which of the following should the nurse plan to use during the group session? ◦ Options: ▪ a. Encourage clients to establish a timeline for their grieving process. ▪ b. Assist clients in identifying ways suicide could have been prevented. ▪ c. Discourage clients from sharing negative aspects of their relationship with the deceased persons. ▪ d. Initiate a discussion with clients about ways to cope with changes in family dynamics. ◦ Correct Answer: d. Initiate a discussion with clients about ways to cope with changes in family dynamics. ◦ Rationale: Discussing coping strategies supports clients in adapting to loss and family changes. Timelines may pressure clients, prevention discussions may induce guilt, and discouraging sharing limits emotional processing. 37. Which of the following risk factors should the nurse include as the best predictor of future violence? ◦ Options: ▪ a. Experiencing delusions. ▪ b. A history of being in prison. ▪ c. Male gender. ▪ d. Previous violent behavior. ◦ Correct Answer: d. Previous violent behavior. ◦ Rationale: Past violent behavior is the strongest predictor of future violence, per evidence-based risk assessments. Delusions, incarceration, or gender may contribute but are less predictive. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 38. Atrial fibrillation places the client at risk for which of the following conditions? ◦ Options: ▪ a. Pulmonary emboli. ▪ b. Cardiac tamponade. ▪ c. Widened pulse pressure. ▪ d. Hemothorax. ◦ Correct Answer: None listed (assumed: stroke, due to thromboembolism). ◦ Rationale: Atrial fibrillation increases the risk of thrombus formation, leading to stroke. Pulmonary emboli, tamponade, widened pulse pressure, and hemothorax are not directly associated. 39. Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? ◦ Options: ▪ a. Refer to the hallucinations as if they are real. ▪ b. Encourage the client to lie down in a quiet room. ▪ c. Ask the client directly what he is hearing. ▪ d. Avoid eye contact with the client. ◦ Correct Answer: c. Ask the client directly what he is hearing. ◦ Rationale: Asking about hallucinations helps assess their content and potential for harm (e.g., command hallucinations). Validating hallucinations as real may reinforce delusions, a quiet room is secondary, and avoiding eye contact may increase distrust. 40. Circumcised newborn. Which of the following instructions should the nurse include in the teaching? ◦ Options: ▪ a. “Wrap sterile gauze around the penis if bleeding occurs.” ▪ b. “Use soap to cleanse the site.” ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ c. “Apply petroleum jelly to the glans with diaper changes.” ▪ d. “Remove yellow exudate around the penis.” ◦ Correct Answer: c. “Apply petroleum jelly to the glans with diaper changes.” ◦ Rationale: Petroleum jelly prevents the diaper from sticking to the circumcision site, promoting healing. Soap may irritate, sterile gauze is unnecessary, and yellow exudate is normal and should not be removed. 41. Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? ◦ Options: ▪ a. Schilling test. ▪ b. Oral glucose tolerance test. ▪ c. D-dimer test. ▪ d. Thyroid scan. ◦ Correct Answer: a. Schilling test. ◦ Rationale: The Schilling test assesses vitamin B12 absorption, used to diagnose pernicious anemia. The other tests are unrelated (glucose for diabetes, D-dimer for clotting, thyroid scan for thyroid disorders). 42. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? ◦ Options: ▪ a. Administer atropine to the client if tachycardia is present. ▪ b. Maintain the indwelling urinary catheter until the client is ready for discharge. ▪ c. Prepare for fluid volume replacement if the central venous pressure steadily increases. ▪ d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Correct Answer: d. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr. ◦ Rationale: Drainage exceeding 150 mL/hr post-CABG suggests hemorrhage, requiring hemoglobin assessment to evaluate blood loss. Atropine is for bradycardia, catheters are removed early, and increased CVP may indicate tamponade, not fluid replacement. 43. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? ◦ Options: ▪ a. Morphine. ▪ b. Digoxin. ▪ c. Prednisone. ▪ d. Omeprazole. ◦ Correct Answer: c. Prednisone. ◦ Rationale: Prednisone, a corticosteroid, impairs wound healing by suppressing inflammation and immune response. The other medications do not significantly affect healing. 44. Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining the client does not have a palpable pulse? ◦ Options: ▪ a. Establish IV access. ▪ b. Administer epinephrine. ▪ c. Defibrillate. ▪ d. Assess heart sounds. ◦ Correct Answer: c. Defibrillate. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Rationale: Ventricular tachycardia with pulselessness is a shockable rhythm. Immediate defibrillation is the priority per ACLS guidelines to restore rhythm. IV access and epinephrine follow, and heart sounds are irrelevant in this emergency. 45. A nurse is caring for several clients on a med-surg unit. For which of the following nursing activities is it required that the nurse use sterile gloves? ◦ Options: ▪ a. Initiating IV access. ▪ b. Performing tracheostomy care. ▪ c. Inserting an NG tube. ▪ d. Administering total parenteral nutrition through a central venous access device. ◦ Correct Answer: b. Performing tracheostomy care. ◦ Rationale: Tracheostomy care requires sterile gloves to prevent infection in the open airway. IV access, NG tube insertion, and TPN administration use clean technique, as they involve less risk of infection. 46. Lab results s/p surgery. Which should be reported to the provider? ◦ Options: ▪ a. Na 160 mEq/L. ▪ b. Cl 100 mEq/L. ▪ c. Bicarbonate 26 mEq/L. ▪ d. K 3.8 mEq/L. ◦ Correct Answer: a. Na 160 mEq/L. ◦ Rationale: A sodium level of 160 mEq/L (hypernatremia) can cause neurological symptoms and requires immediate reporting. The other values are within normal ranges (Cl 98–106, bicarbonate 22–28, K 3.5–5.0). 47. Nurse is developing a care plan for a client on Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which should the nurse delegate to an AP? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Observe the position of the suspended weight. ▪ b. Remind the client to use the incentive spirometer. ▪ c. Check the client’s pedal pulse on the right leg. ▪ d. Ask client to describe her pain. ◦ Correct Answer: b. Remind the client to use the incentive spirometer. ◦ Rationale: Reminding a client to use an incentive spirometer is within the AP’s scope. Observing weights, checking pulses, and assessing pain require nursing judgment and cannot be delegated. 48. Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect? ◦ Options: ▪ a. Decreased appetite. ▪ b. Runny nose. ▪ c. Muscle spasms. ▪ d. Fatigue. ◦ Correct Answer: d. Fatigue. ◦ Rationale: Stimulant withdrawal (e.g., cocaine, amphetamines) causes fatigue, depression, and increased appetite due to CNS depression. Runny nose is typical of opioid withdrawal, and muscle spasms are not common. 49. Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the client’s admission data? ◦ Options: ▪ a. Allow client’s partner to translate. ▪ b. Request female interpreter through the facility. ▪ c. Have client’s child translate. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ d. Ask nursing student who speaks the same language as the client to translate. ◦ Correct Answer: b. Request female interpreter through the facility. ◦ Rationale: A professional interpreter ensures accurate, confidential communication, especially for sensitive postpartum assessments. A female interpreter may be preferred for cultural comfort. Family or students may introduce bias or errors. 50. Operating fire extinguisher [arrange the steps]: ◦ Steps: ▪ Unlock the handle by pulling on the pin. ▪ Point the hose at the base of the fire. ▪ Squeeze the handle. ▪ Sweep the extinguisher from side to side. ◦ Correct Answer: 1, 2, 3, 4. ◦ Rationale: The PASS technique (Pull, Aim, Squeeze, Sweep) ensures effective fire extinguisher use. The corrected sequence removes the erroneous reference to the pin in step 3. 51. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses should the nurse make? ◦ Options: ▪ a. “Are you not happy with your treatment?” ▪ b. “Why are you interested in seeing your therapist’s notes?” ▪ c. “I don’t think you will benefit from reviewing your therapist’s notes right now.” ▪ d. “We can provide a copy of your records, but the therapist’s notes are not included.” ◦ Correct Answer: d. “We can provide a copy of your records, but the therapist’s notes are not included.” ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Rationale: Under HIPAA, psychotherapy notes are protected and excluded from client access unless authorized by the therapist. This response respects legal boundaries while addressing the request. 52. A nurse is assessing a client who has hypervolemia. Which of the findings should the nurse expect? ◦ Options: ▪ a. Urinary frequency. ▪ b. Decreased BP. ▪ c. Bounding pulse. ▪ d. Bradycardia. ◦ Correct Answer: c. Bounding pulse. ◦ Rationale: Hypervolemia (fluid overload) causes increased cardiac workload, leading to a bounding pulse. Urinary frequency is not typical, BP is usually elevated, and tachycardia (not bradycardia) may occur. 53. Inserting indwelling urinary catheter to a male client. Which of the following actions should the nurse take? ◦ Options: ▪ a. Cleanse the tip of the penis in a side-to-side motion. ▪ b. Pick up the catheter 13 cm (5 in) from its tip. ▪ c. Perform the cleansing procedure with a fresh swab two times. ▪ d. Lift the penis so that it is perpendicular to the client’s body. ◦ Correct Answer: d. Lift the penis so that it is perpendicular to the client’s body. ◦ Rationale: Lifting the penis perpendicular facilitates catheter insertion into the urethra. Cleansing is done in a circular motion, the catheter is held 2–3 inches from the tip, and multiple swabs are used until clean. 54. A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Tachycardia. ▪ b. Flushing. ▪ c. Shivering. ▪ d. Restlessness. ◦ Correct Answer: c. Shivering. ◦ Rationale: Shivering is an adverse reaction to a cooling blanket, as it increases metabolic rate and counteracts fever reduction. Tachycardia, flushing, or restlessness may occur but are not specific to cooling. 55. Teaching for misoprostol. Which information should be included in the teaching? ◦ Options: ▪ a. “You will have a urinary catheter inserted prior to the placement of the medication.” ▪ b. “You will lie on your side for 30 min after the medication is inserted.” ▪ c. “You will have oxytocin initiated within 3 hours of administration of the medication.” ▪ d. “You will have intermittent fetal monitoring while you receive the medication.” ◦ Correct Answer: b. “You will lie on your side for 30 min after the medication is inserted.” ◦ Rationale: Misoprostol (for labor induction or abortion) is inserted vaginally, and lying on the side for 30 minutes ensures absorption. Catheters, oxytocin, or intermittent monitoring are not standard. 56. Client in psychiatric unit. The client states, “The voices are telling me to jump.” Which of the following is an appropriate response by the nurse? ◦ Options: ▪ a. “That can’t be true. The only voices in this room are yours and mine.” ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ b. “You shouldn’t be afraid when you think the voices are telling you to hurt yourself.” ▪ c. “I understand the voices are frightening you, but I do not hear any voices.” ▪ d. “Do you recognize the voices as belonging to anyone you know?” ◦ Correct Answer: c. “I understand the voices are frightening you, but I do not hear any voices.” ◦ Rationale: This response validates the client’s experience while gently reinforcing reality, promoting trust. Denying the voices, minimizing fear, or focusing on voice identity may escalate distress or harm risk. 57. Teaching the parent of an infant who has positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? ◦ Options: ▪ a. “I should place my baby in the left side-lying position at night when using the helmet.” ▪ b. “I should avoid tummy time when my baby is wearing the helmet.” ▪ c. “I should expect to have my baby wear this helmet for 10 months.” ▪ d. “I should keep the helmet on my baby for 23 hours a day.” ◦ Correct Answer: d. “I should keep the helmet on my baby for 23 hours a day.” ◦ Rationale: Helmet therapy for plagiocephaly requires 23 hours/day wear for optimal correction, with brief removal for hygiene. Tummy time is encouraged, side-lying is not specific, and duration is typically 3–6 months. 58. Which of the following lab findings should the nurse recognize as indicative of rheumatic fever? ◦ Options: ▪ a. Decreased hgb and platelet count. ▪ b. Decreased myoglobin and antinuclear antibody titer. ▪ c. Elevated sedimentation rate and C-reactive protein. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ d. Elevated creatine kinase and troponin. ◦ Correct Answer: c. Elevated sedimentation rate and C-reactive protein. ◦ Rationale: Rheumatic fever causes systemic inflammation, reflected by elevated ESR and CRP. Decreased hemoglobin/platelets, myoglobin/ANA, or cardiac enzymes are not specific to rheumatic fever. 59. Client with pneumonia gained 4.2 kg (9.3 lb.) over the last 5 days. Lab values this morning are: WBC 10,000/mm³, RBC 5.2 million/mm³, platelets 250,000/mm³, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? ◦ Options: ▪ a. Nephrologist. ▪ b. Cardiologist. ▪ c. Infectious disease nurse. ▪ d. Dietitian. ◦ Correct Answer: a. Nephrologist. ◦ Rationale: Weight gain, elevated BUN (32 mg/dL), and creatinine (2.1 mg/dL) suggest renal impairment, possibly due to fluid overload or glomerulonephritis. A nephrologist should be consulted for further evaluation. 60. A nurse received change-of-shift report. Which of the following actions should the nurse take to manage time effectively? ◦ Options: ▪ a. Focus on several client tasks at a time. ▪ b. Document client care at the end of the shift. ▪ c. Skip breaks until client tasks are completed. ▪ d. Make a client to-do list for the day. ◦ Correct Answer: d. Make a client to-do list for the day. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Rationale: A to-do list prioritizes tasks and enhances time management. Multitasking may lead to errors, delayed documentation risks inaccuracies, and skipping breaks can cause fatigue. 61. Protocols for belt restraints. Which of the following guidelines should the nurse include? ◦ Options: ▪ a. Remove the client’s restraint every 4 hr. ▪ b. Request a PRN restraint prescription for clients who are aggressive. ▪ c. Attach the restraint to the bed’s side rails. ▪ d. Document the client’s condition every 15 min. ◦ Correct Answer: d. Document the client’s condition every 15 min. ◦ Rationale: Restraint protocols require frequent monitoring (every 15 min) to ensure safety and assess for complications. Restraints are removed every 2 hours, PRN orders are not allowed, and attaching to side rails is unsafe. 62. Assessing client in ER. Which of the following actions should the nurse take first? [View Exhibit] ◦ Options: ▪ a. Obtain ABG levels. ▪ b. Elevate the head of the client’s bed to 30°. ▪ c. Place client on a cooling blanket. ▪ d. Administer an analgesic. ◦ Correct Answer: b. Elevate the head of the client’s bed to 30°. ◦ Rationale: Without the exhibit, elevating the bed to 30° is a safe, non-invasive action that promotes respiratory comfort in many ER scenarios (e.g., dyspnea). ABGs, cooling, or analgesics require specific indications. 63. Client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? ◦ Options: ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ a. “I can continue to take St. John’s wort while taking this medication.” ▪ b. “I know it will be a couple of weeks before the medication helps me feel better.” ▪ c. “I expect this medication to raise my blood pressure.” ▪ d. “I should take this medication on an empty stomach.” ◦ Correct Answer: b. “I know it will be a couple of weeks before the medication helps me feel better.” ◦ Rationale: Amitriptyline, a tricyclic antidepressant, takes 2–4 weeks for therapeutic effects. St. John’s wort increases serotonin syndrome risk, hypotension (not hypertension) is a side effect, and it can be taken with food. 64. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? ◦ Options: ▪ a. Instruct the client to lift her chin when swallowing. ▪ b. Sit at or below the client’s eye level during feedings. ▪ c. Talk with the client during her feeding. ▪ d. Discourage the client from coughing during feedings. ◦ Correct Answer: b. Sit at or below the client’s eye level during feedings. ◦ Rationale: Sitting at or below eye level promotes a calm, supportive environment and reduces aspiration risk. Tucking the chin (not lifting) aids swallowing, talking may distract, and coughing is a protective mechanism. 65. Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? ◦ Options: ▪ a. A low-protein diet. ▪ b. Adequate hydration. ▪ c. Calorie restriction. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ d. Increased iron intake. ◦ Correct Answer: b. Adequate hydration. ◦ Rationale: Hydration prevents blood viscosity and sickling, reducing crisis risk. Protein and calories support growth, and excess iron is harmful in sickle cell anemia. 66. Client with indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? ◦ Options: ▪ a. Provide perineal hygiene after defecation. ▪ b. Empty the collected urine once every 24 hr. ▪ c. Hang the drainage bag on a bed rail. ▪ d. Change the indwelling catheter every 8 hr. ◦ Correct Answer: a. Provide perineal hygiene after defecation. ◦ Rationale: Perineal hygiene prevents infection. Urine should be emptied every 4– 8 hours, the bag kept below bladder level (not on rails), and catheters changed per protocol (e.g., every 4 weeks). 67. Client experiencing acute mania. Which of the foods should the nurse provide for this client? ◦ Options: ▪ a. Peanut butter sandwich. ▪ b. Chicken noodle soup. ▪ c. Celery sticks. ▪ d. Oatmeal with butter. ◦ Correct Answer: a. Peanut butter sandwich. ◦ Rationale: A peanut butter sandwich is portable, high-calorie, and easy to eat, suitable for a client with high energy and distractibility during mania. Soup, celery, and oatmeal are less practical. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 69. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? ◦ Options: ▪ a. Client who reports being given sedative medications by family members. ▪ b. Client who is taking warfarin and has several small bruises on her shins and hands. ▪ c. Client who schedules multiple visits with his provider every month. ▪ d. Client who lives with family members and begins to take more responsibility for self-care. ◦ Correct Answer: a. Client who reports being given sedative medications by family members. ◦ Rationale: Administering sedatives without medical oversight suggests potential chemical restraint or abuse. Bruises on warfarin are expected, frequent visits may indicate health needs, and increased self-care is positive. 70. A nurse is caring for a school-age child who is postoperative and received morphine IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority? ◦ Options: ▪ a. Bradypnea. ▪ b. Sedation. ▪ c. Euphoria. ▪ d. Constipation. ◦ Correct Answer: a. Bradypnea. ◦ Rationale: Bradypnea indicates respiratory depression, a life-threatening side effect of morphine. Sedation and euphoria are expected, and constipation is a later concern. 71. A nurse is planning to administer 2 units of packed RBCs to an older adult who has anemia. Which of the following actions should the nurse plan to take? (SATA) ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Prime the infusion tubing with 0.45 NaCl. ▪ b. Infuse blood over 4 hr. ▪ c. Don sterile gloves to prepare blood administration setup. ▪ d. Assess the client’s lung sounds prior to the infusion. ▪ e. Verify with another nurse that the unit of blood is compatible with the client’s blood type. ◦ Correct Answer: b. Infuse blood over 4 hr, d. Assess the client’s lung sounds prior to the infusion, e. Verify with another nurse that the unit of blood is compatible with the client’s blood type. ◦ Rationale: Blood is infused over 2–4 hours, lung sounds assess for fluid overload risk, and verification ensures safety. Normal saline (0.9% NaCl) is used for priming, and clean gloves are sufficient. 72. A nurse is planning care for a client who is scheduled to receive a PICC in the arm. Which of the following interventions is appropriate for the nurse to include in the Skull plan of care? ◦ Options: ▪ a. Administer sedation for the procedure. ▪ b. Measure the arm circumference above the insertion site daily. ▪ c. Use gauze to secure an arm board to the involved extremity. ▪ d. Schedule an MRI postprocedure to verify placement. ◦ Correct Answer: b. Measure the arm circumference above the insertion site daily. ◦ Rationale: Measuring arm circumference monitors for complications like thrombosis or infection. Sedation is not routine, arm boards are not typically needed, and chest X-ray (not MRI) confirms placement. 73. Which of the following clients should the nurse place near the nurses’ station? ◦ Options: ▪ a. A client who is in Buck’s traction. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ b. A client who has orthostatic hypotension. ▪ c. A client who has an open wound. ▪ d. A client who is on fluid restriction. ◦ Correct Answer: b. A client who has orthostatic hypotension. ◦ Rationale: Orthostatic hypotension increases fall risk, necessitating close monitoring. Traction, wounds, and fluid restriction require standard care but not proximity to the station. 74. Older client transferred from another facility. Nurse notes ulcers on the coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? ◦ Options: ▪ a. Notify risk management. ▪ b. Inform the transferring agency of the client’s condition. ▪ c. Privately interview the client about her condition. ▪ d. Contact the family regarding the client’s condition. ◦ Correct Answer: c. Privately interview the client about her condition. ◦ Rationale: A private interview allows the client to disclose abuse safely. Notifying risk management or the agency follows, but the client’s account is the priority. Contacting family may compromise safety if they are involved. 75. Client receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? ◦ Options: ▪ a. History of GERD. ▪ b. Sitting in a high-Fowler’s position during the feeding. ▪ c. A residual of 65 mL 1 hr. postprandial. ▪ d. Receiving a high osmolarity formula. ◦ Correct Answer: a. History of GERD. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Rationale: GERD increases aspiration risk due to reflux. High-Fowler’s position reduces risk, 65 mL residual is acceptable, and high osmolarity may cause diarrhea, not aspiration. 76. Adverse effects of sertraline. ◦ Options: ▪ a. Dry cough. ▪ b. Increased urinary frequency. ▪ c. Metallic taste in mouth. ▪ d. Excessive sweating. ◦ Correct Answer: d. Excessive sweating. ◦ Rationale: Sertraline, an SSRI, commonly causes sweating as a side effect, especially with serotonin syndrome risk. Cough, urinary frequency, and metallic taste are not typical. 77. Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client indicates an understanding of the teaching? ◦ Options: ▪ a. “I should limit my intake of dairy products to prevent nausea.” ▪ b. “I should use a soft-bristle toothbrush to clean my teeth after meals.” ▪ c. “I should moisten my lips with lemon-glycerin swabs.” ▪ d. “I should gargle with an alcohol-based mouthwash to kill germs.” ◦ Correct Answer: b. “I should use a soft-bristle toothbrush to clean my teeth after meals.” ◦ Rationale: A soft-bristle toothbrush prevents irritation of stomatitis. Dairy does not prevent nausea, lemon-glycerin swabs dry the mouth, and alcohol mouthwash worsens irritation. 78. Client placed in seclusion and restraints. Which of the following actions should the nurse plan to take? ◦ Options: ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ a. Ensure that the prescription for restraints be renewed every 6 hr. ▪ b. Have a provider evaluate the client in person within 1 hr. ▪ c. Plan to monitor the client every 30 min while restrained. ▪ d. Complete a written record regarding the seclusion and restraint every 2 hr. ◦ Correct Answer: b. Have a provider evaluate the client in person within 1 hr. ◦ Rationale: CMS guidelines require a provider evaluation within 1 hour of initiating restraints/seclusion. Renewals are every 4 hours (adults), monitoring is every 15 minutes, and documentation is ongoing. 79. Client with acute glomerulonephritis. Which of the following food choices should the nurse recommend? (low in potassium, sodium, and protein) ◦ Options: ▪ a. Bagel. ▪ b. Banana. ▪ c. Eggs. ▪ d. Smoked salmon. ◦ Correct Answer: a. Bagel. ◦ Rationale: A bagel is low in potassium, sodium, and protein, suitable for glomerulonephritis. Bananas (high potassium), eggs (high protein), and smoked salmon (high sodium) are contraindicated. 80. Client asks about acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? ◦ Options: ▪ a. HTN. ▪ b. Herpes zoster. ▪ c. Obesity. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ d. Hypothyroidism. ◦ Correct Answer: b. Herpes zoster. ◦ Rationale: Active herpes zoster is a contraindication for acupuncture due to infection risk. HTN, obesity, and hypothyroidism are not absolute contraindications but require monitoring. 81. Reviewing client’s lab results. Which of the following should the nurse review to evaluate the client’s nutritional status? ◦ Options: ▪ a. Serum albumin. ▪ b. Serum sodium. ▪ c. Troponin. ▪ d. ESR. ◦ Correct Answer: a. Serum albumin. ◦ Rationale: Serum albumin reflects protein status and nutrition. Sodium assesses electrolytes, troponin indicates cardiac damage, and ESR measures inflammation. 82. Nurse manager observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following should the nurse manager take first? ◦ Options: ▪ a. Request the nurses present an in-service on client confidentiality. ▪ b. Place documentation of the nurses’ actions in the personnel file. ▪ c. Instruct the nurses to close the client’s computer record. ▪ d. Advise the nurses to read the facility’s confidentiality policy. ◦ Correct Answer: c. Instruct the nurses to close the client’s computer record. ◦ Rationale: Stopping the breach immediately protects client confidentiality. Further actions (education, documentation) follow, but closing the record is the priority. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers 83. Discharge teaching to a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? ◦ Options: ▪ a. Use gestures to convey meaning. ▪ b. Speak slowly when talking to the interpreter. ▪ c. Speak directly to the client. ▪ d. Pause in the middle of the sentences. ◦ Correct Answer: c. Speak directly to the client. ◦ Rationale: Speaking directly to the client through the interpreter promotes engagement and respect. Gestures may confuse, speaking to the interpreter shifts focus, and pausing disrupts flow. 84. Teaching the parents of a client with new onset of seizures and is to undergo an EEG. Which of the following instructions should the nurse include in the teaching? ◦ Options: ▪ a. “Ensure the child’s hair is clean and without conditioner before the procedure.” ▪ b. “Keep the child out of the sun for 4 hr. following the procedure.” ▪ c. “Make the child NPO before the procedure.” ▪ d. “Give the child acetaminophen for pain following the procedure.” ◦ Correct Answer: a. “Ensure the child’s hair is clean and without conditioner before the procedure.” ◦ Rationale: Clean hair without oils or conditioner ensures accurate EEG electrode placement. Sun exposure, NPO status, and pain are not relevant to EEG preparation. 85. Client presented with fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? ◦ Options: ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ a. Hyperthyroidism. ▪ b. Hyperparathyroidism. ▪ c. Hypothyroidism. ▪ d. Hypoparathyroidism. ◦ Correct Answer: a. Hyperthyroidism. ◦ Rationale: Hyperthyroidism causes fine hair, exophthalmos, and heat intolerance due to increased metabolism. Other disorders do not present with this combination of symptoms. 86. Client on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? ◦ Options: ▪ a. Decreased serum calcium levels. ▪ b. Increased BP. ▪ c. Urinary frequency. ▪ d. Swollen area on calf. ◦ Correct Answer: d. Swollen area on calf. ◦ Rationale: A swollen calf suggests deep vein thrombosis, a common immobility complication. Immobility may increase calcium, decrease BP, and cause urinary retention, not frequency. 87. A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? ◦ Options: ▪ a. Administer nitroglycerin 0.4 mg SL 30 min before the procedure. ▪ b. Draw blood specimens for culture and sensitivity. ▪ c. Transport the client to radiology for a CT scan. ▪ d. Obtain CBC with differential. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Correct Answer: d. Obtain CBC with differential. ◦ Rationale: A CBC assesses for anemia or infection risk before catheterization. Nitroglycerin is not routine pre-procedure, cultures are for suspected infection, and CT is not standard. 88. A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching? ◦ Options: ▪ a. “This test should be performed after your baby is 24 hours old.” ▪ b. “A nurse will draw blood from your baby’s inner elbow.” ▪ c. “This test will be repeated when your baby is 2 months old.” ▪ d. “Your baby will be given 2 ounces of water to drink prior to the test.” ◦ Correct Answer: a. “This test should be performed after your baby is 24 hours old.” ◦ Rationale: Newborn screening is done after 24 hours to ensure accurate results. Blood is typically from a heel stick, repeat testing depends on results, and water is not given. 89. New prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? ◦ Options: ▪ a. “Take with a protein shake.” ▪ b. “Report dark-colored urine.” ▪ c. “Monitor for hyperglycemia.” ▪ d. “Change positions slowly.” ◦ Correct Answer: d. “Change positions slowly.” ◦ Rationale: Carbidopa-levodopa can cause orthostatic hypotension, so slow position changes prevent falls. Protein may reduce absorption, dark urine is not a concern, and hyperglycemia is not typical. 90. Identify ECG [IMAGE] of client with potassium toxicity. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Correct Answer: Not applicable (image-based question). ◦ Rationale: Hyperkalemia ECG shows peaked T waves, widened QRS, and flattened P waves. Without the image, the nurse should assess for these changes and correlate with serum potassium. 91. Client in postpartum taking methylergonovine. The nurse should recognize that which of the following is a contraindication for this medication? ◦ Options: ▪ a. HTN. ▪ b. Polyuria. ▪ c. Confusion. ▪ d. Chlamydia. ◦ Correct Answer: a. HTN. ◦ Rationale: Methylergonovine, used for postpartum hemorrhage, is contraindicated in hypertension due to its vasoconstrictive effects. Polyuria, confusion, and chlamydia are not contraindications. 92. Parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? ◦ Options: ▪ a. Position the nipple at the front of the infant’s mouth. ▪ b. Burp the infant frequently during feedings. ▪ c. Use feeding devices without nipples. ▪ d. Hold the infant in a supine position. ◦ Correct Answer: b. Burp the infant frequently during feedings. ◦ Rationale: Frequent burping reduces air swallowing in infants with cleft lip/ palate. Specialized nipples are used, not avoided, and semi-upright positioning prevents aspiration. 93. Client with Alzheimer’s disease. Which of the following should the nurse include in the plan of care? ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ◦ Options: ▪ a. Encourage physical activity prior to bedtime. ▪ b. Replace the carpet with hardwood floors. ▪ c. Wear clothing with zippers instead of buttons. ▪ d. Place locks at the top of exterior doors. ◦ Correct Answer: d. Place locks at the top of exterior doors. ◦ Rationale: High locks prevent wandering, a common Alzheimer’s risk. Activity before bed may disrupt sleep, hardwood floors increase fall risk, and zippers are not a priority. 94. A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? ◦ Options: ▪ a. Acrocyanosis. ▪ b. Bulging fontanels. ▪ c. Bradycardia. ▪ d. Hypertonicity. ◦ Correct Answer: d. Hypertonicity. ◦ Rationale: Neonatal abstinence syndrome from methadone includes hypertonicity, irritability, and tremors. Acrocyanosis is normal, bulging fontanels suggest other issues, and tachycardia (not bradycardia) is typical. 95. A newly LPN working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? ◦ Options: ▪ a. Using an electronic messaging system to remind clients when to take medications. ▪ b. Educating clients about contraindications to specific immunizations. ATI Comprehensive Exit Retake Exam 2025 Questions and Answers ▪ c. Helping clients understand health screenings covered by their insurance plans. ▪ d. Providing clients with info about the benefits of exercise. ◦ Correct Answer: a. Using an electronic messaging system to remind clients when to take medications. ◦ Rationale: Tertiary prevention manages existing disease to prevent complications, like medication adherence in HIV. The other options are primary (exercise, education) or secondary (screenings) prevention. 96. Client who has bipolar disorder and is experiencing mania. Which of the following should the nurse include in the plan? ◦ Options: ▪ a. Encourage the client to take frequent rest periods. ▪ b. Encourage the client to spend time in the day room. ▪ c. Place the client in seclusion when he exhibits signs of anxiety. ▪ d. Withdraw the client’s TV privileges if he does not attend group therapy. ◦ Correct Answer: a. Encourage the client to take frequent rest periods. ◦ Rationale: Mania involves high energy, and rest periods reduce overstimulation. The day room may increase stimulation, seclusion is a last resort, and withdrawing privileges is punitive. 97. A nurse in the ER is receiving report for four clients. Which should the nurse see first? ◦ Options: ▪ a. Client who has HTN and reports severe headache. ▪ b. Client who reports left arm pain following a fall. ▪ c. Client who has heart failure and received diuretic 30 min