ATI COMPREHENSIVE EXIT EXAM MULTIPLE QUESTIONS.

1. A patient’s father died a week ago. Both the patient and the patient’s
spouse talk about the death. The patient’s spouse is experiencing headaches
and fatigue. The patient is having trouble sleeping, has no appetite, and gets
choked up most of the time. How should the nurse interpret these findings as
the basis for a follow-up assessment?
a. The patient is dying and the spouse is angry.

b. The patient is ill and the spouse is malingering.

c. Both the patient and the spouse are likely in denial.
d. Both the patient and the spouse are likely grieving.

ANS: D

Both are likely grieving from the loss of the patient’s father. Symptoms of
normal grief include headache, fatigue, insomnia, appetite disturbance, and
choking sensation. Different people manifest different symptoms. There is no
data to support the spouse is angry or malingering. There is no data to support
the patient is dying or ill. Denial is assessed when the person cannot accept
the loss; both talked about the loss.
MULTIPLE RESPONSE
1. A nurse is documenting end-of-life care. Which information will the
nurse include in the patient’s electronic medical record? (Select all that
apply.)
a. Reason for the death

b. Time and date of death

c. How ethically the family grieved

d. Location of body identification tags

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e. Time of body transfer and destination
ANS: B, D, E
Documentation of end-of-life care includes the following: time and date of
death, location of body identification tags, time of body transfer and
destination and personal articles left on and secured to the body. Reason for
the death is not appropriate; this is a medical judgment and not a nursing
judgment. How ethically the family grieved is judgmental and does not belong
in the chart. We must remain open to the varying views and beliefs of grieving
that are in contrast to our own in order to best support and care for our patients
and their families.

Week 3
Safety and Fall Prevention among Older Adults, Preventing Complications of
Immobility
1. A home health nurse is performing a home assessment for safety.
Which comment by the patient will cause the nurse to follow up?
“Every December is the time to change batteries on the carbon
a. monoxide detector.”
b. “I will schedule an appointment with a chimney inspector next week.”

c. “If I feel dizzy when using the heater, I need to have it inspected.”
d. “When it is cold outside in the winter, I will use a nonvented furnace.”

ANS: D
Using a nonvented heater introduces carbon monoxide into the environment
and decreases the available oxygen for human consumption and the nurse
should follow up to correct this behavior. Checking the chimney and heater,
changing the batteries on the detector, and following up on symptoms such
as dizziness, nausea, and fatigue are all statements that are safe and
appropriate and need no follow-up.
2. The nurse is caring for an older-adult patient admitted with nausea,
vomiting, and diarrhea due to food poisoning. The nurse completes the
health history. Which priority concern will require collaboration with
social services to address the patient’s health care needs?
a. The electricity was turned off 3 days ago.
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b. The water comes from the county water supply.
c. A son and family recently moved into the home.
d. This home is not furnished with a microwave oven.

ANS: A
Electricity is needed for refrigeration of food, and lack of electricity could
have contributed to the nausea, vomiting, and diarrhea due to food poisoning.
This discussion about the patient’s electrical needs can be referred to social
services. Foods that are inadequately prepared or stored or subject to
unsanitary conditions increase the patient’s risk for infections and food
poisoning, and an assessment should include storage practices. The water
supply, the increased number of individuals in the home, and not having a
microwave may or may not be concerns but do not pertain to the current
health care needs of this patient.
3. The patient has been diagnosed with a respiratory illness and reports
shortness of breath. The nurse adjusts the temperature to facilitate the
comfort of the patient. At which temperature range will the nurse set the
thermostat?
a. 60° to 64° F

b. 65° to 75° F
c. 15° to 17° C
d. 25° to 28° C

ANS: B

A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F).
The other ranges are too low or too high and do not reflect the average person’s
comfort zone.
4. A homeless adult patient presents to the emergency department. The
nurse obtains the following vital signs: temperature 94.8° F, blood pressure
106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the
nurse address immediately?
a. Respiratory rate
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b. Temperature
c. Apical pulse
d. Blood pressure

ANS: B
The temperature indicates the patient is experiencing hypothermia.
Homeless individuals are more at risk for hypothermia. While all the vital
signs are low, the most critical vital sign at this time is the temperature.
5. A nurse is teaching the patient and family about wound care.

Which technique will the nurse teach to best prevent transmission of

pathogens?
a. Wash hands

b. Wash wound
c. Wear gloves
d. Wear eye protection

ANS: A
One of the most effective methods for limiting the transmission of pathogens
is the medically aseptic practice of hand hygiene. The most common means of
transmission of pathogens is by the hands. While washing the wound is
needed, the best method to prevent transmission is hand hygiene. Wearing
gloves and possibly eye protection help protect the nurse, but handwashing is
best for limiting the transmission of pathogens.
6. The nurse is monitoring for Never Events. Which finding indicates the
nurse will report a Never Event?
a. No blood incompatibility occurs with a blood transfusion.

b. A surgical sponge is left in the patient’s incision.

c. Pulmonary embolism after lung surgery
d. Stage II pressure ulcer

ANS: B
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The Centers for Medicare and Medicaid Services names select serious
reportable events as Never Events (i.e., adverse events that should never
occur in a health care setting). A surgical sponge left in a patient’s incision is
a Never Event. No blood incompatibility reaction is safe practice. Pulmonary
embolism after certain orthopedic procedures is like a total knee and hip
replacement. Stage III and IV pressure ulcers are Never Events.
7. The nurse discovers a patient on the floor. The patient states that he

fell out of bed. The nurse assesses the patient and places the patient back in
bed. Which action should the nurse take next?
a. Do nothing, no harm has occurred.

b. Notify the health care provider.

c. Complete an incident report.
d. Assess the patient.

ANS: B

Report immediately to physician or health care provider if the patient sustains

a fall or an injury. The nurse must provide safe care, and doing nothing is not
safe care. The scenario indicates the nurse has already assessed the patient.
After the patient has stabilized, completing an incident report would be the
last step in the process.
8. When making rounds the nurse observes a purple wristband on a

patient’s wrist. How will the nurse interpret this finding?

a. The patient is allergic to certain medications or foods.

b. The patient has do not resuscitate preferences.

c. The patient has a high risk for falls.
d. The patient is at risk for seizures.

ANS: B
In 2008 the American Hospital Association issued an advisory recommending
that hospitals standardize wristband colors: red for patient allergies, yellow for
fall risk, and purple for do not resuscitate preferences. Purple does not indicate
seizures.
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9. A nurse reviews the history of a newly admitted patient. Which finding
will alert the nurse that the patient is at risk for falls?
a. 55 years old

b. 20/20 vision
c. Urinary continence
d. Orthostatic hypotension

ANS: D
Numerous factors increase the risk of falls, including a history of falling,
being age 65 or over, reduced vision, orthostatic hypotension, lower
extremity weakness, gait and balance problems, urinary incontinence,
improper use of walking aids, and the effects of various medications (e.g.,
anticonvulsants, hypnotics, sedatives, certain analgesics).
10. The nurse is assessing a patient for lead poisoning. Which patient is the
nurse most likely assessing?
a. Young infant

b. Toddler
c. Preschooler
d. Adolescent

ANS: B
The incidence of lead poisoning is highest in late infancy and toddlerhood.
Children at this stage explore the environment and, because of their increased
level of oral activity, put objects in their mouths. Young infant is too young. A
preschooler and an adolescent are too old.

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