ATI Comp Retake

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Sample questions from ATI Comp Retake

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 72-year-old with chronic heart failure who has bilateral ankle edema and an oxygen saturation of 94% on room air, unchanged from yesterday
   • B.A 35-year-old with a fractured wrist who reports pain of 8/10 after the last analgesic dose 5 hours ago
   • C.A 58-year-old with pneumonia who has a temperature of 38.1 C after receiving an antipyretic 2 hours ago
   • D.A 46-year-old 6 hours after thyroidectomy who is restless and reports tingling around the mouth; respiratory rate is 24/min and oxygen saturation is 95%

   Rationale: The client recently had thyroid surgery and now has restlessness and perioral tingling, which can signal hypocalcemia and evolving laryngospasm; prompt assessment of airway and calcium-related symptoms is the priority. The heart failure findings are chronic and unchanged, and the fever and wrist pain require care but do not suggest an immediate airway threat. Assessing and treating the wrist pain is appropriate after the urgent postoperative concern is addressed.

2. 2.In a community clinic, a 16-year-old with type 1 diabetes reports vomiting and missed insulin doses. The client is alert, has deep respirations, a blood glucose of 428 mg/dL, and moderate urine ketones. Which action should the nurse take first?

   • A.Arrange immediate emergency department evaluation and communicate the concern for diabetic ketoacidosis
   • B.Ask the parent to supervise the client's insulin administration at home tonight
   • C.Teach the client to give the usual meal-time insulin after tolerating food
   • D.Schedule a diabetes educator appointment for later this week

   Rationale: Vomiting, missed insulin, marked hyperglycemia, ketones, and deep respirations indicate possible diabetic ketoacidosis, which requires urgent evaluation and treatment. Meal-time insulin teaching and family supervision may help prevent future episodes but do not address the current emergency. A later education appointment would dangerously delay care.

3. 3.During a home visit, a 79-year-old taking warfarin for atrial fibrillation reports a new severe headache and blurred vision after falling and striking the head 2 hours ago. The client is awake, has a blood pressure of 156/88 mm Hg, and has no visible scalp injury. Which actions should the nurse take? Select all that apply.

   • A.Arrange emergency medical evaluation and do not leave the client alone
   • B.Contact emergency services and report the head injury, symptoms, and anticoagulant use
   • C.Keep the client from eating or drinking while awaiting emergency evaluation
   • D.Ask the client to take the next scheduled warfarin dose to avoid interruption of therapy
   • E.Have the client lie down and reassess the headache in 30 minutes before deciding whether to seek care

   Rationale: A new severe headache and visual change after head trauma in a client taking warfarin may indicate intracranial bleeding, so emergency evaluation is needed and the client should not be left alone. Emergency personnel need to know about the fall, symptoms, and anticoagulant use; withholding oral intake is prudent while urgent evaluation may require procedures. Giving warfarin could worsen bleeding, and waiting to reassess could delay life-saving care.

4. 4.A provider prescribes digoxin for a 68-year-old hospitalized with heart failure. Before the scheduled dose, the client reports nausea and seeing yellow halos; the apical pulse is 52/min, and the potassium is 3.0 mEq/L (reference range 3.5 to 5.0 mEq/L). Which action should the nurse take?

   • A.Administer the dose with food and recheck the pulse in 1 hour
   • B.Give the dose and request a potassium supplement for the next scheduled administration
   • C.Hold the dose and notify the provider of the findings
   • D.Ask an assistive personnel to repeat the apical pulse and administer the dose if it is above 50/min

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, a 90-year-old resident with dementia is newly difficult to arouse. The resident has a temperature of 37.8 C, heart rate of 112/min, respiratory rate of 26/min, blood pressure of 94/56 mm Hg, and oxygen saturation of 91% on room air. Which task is appropriate for the nurse to delegate to an experienced practical nurse?

   • A.Perform the initial assessment and determine whether the resident has sepsis
   • B.Obtain a repeat set of vital signs and report the results immediately while the registered nurse assesses the resident
   • C.Decide whether the resident should be transferred to the emergency department
   • D.Teach the resident's family how to recognize early signs of infection

   Answer and rationale are in the full material.