The secrets out! EXACT ATI- RN Concept-Based Assessment Level 2 & 3 nursing exam questions with complete answers. Thousands of students used these to pass their exams successfully.
Nursing Exams
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Purchase For $30/monthThe secrets out! EXACT ATI- RN Concept-Based Assessment Level 2 & 3 nursing exam questions with complete answers. Thousands of students used these to pass their exams successfully.
A nurse in an emergency department is assessing a client following an acute ischemic stroke. Which of the following actions should the nurse take first?
Check the strength of the client’s affected side.
Observe the client’s ability to communicate.
Determine if the client is incontinent of urine.
Evaluate the client’s swallowing capability.
The Correct Answer is:
D. Evaluate the client’s swallowing capability.
Detailed Explanation:
After an acute ischemic stroke, the priority nursing action is to assess the client’s ability to swallow before offering food, fluids, or oral medications. Stroke can cause dysphagia due to impaired cranial nerve function, increasing the risk of aspiration, airway obstruction, and pneumonia.
Once swallowing safety is established, the nurse can proceed with a focused neurological assessment, including motor strength, speech, sensation, and reflexes. Observing communication abilities and assessing for incontinence are also important but occur after ensuring airway protection and preventing aspiration.
This prioritization follows the ABCs of care (Airway, Breathing, Circulation)—airway safety through swallow evaluation always comes first in acute stroke management.
A nurse enters the room of a child who has epilepsy and is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Time the seizure episode.
Place the child in a prone position.
Attempt to restrain the child.
Administer hydralazine IV
Correct Answer:
A. Time the seizure episode.
Explanation of Correct Answer
The first action the nurse should take when witnessing a tonic-clonic seizure is to time the seizure episode. Knowing the duration is crucial for determining if it becomes status epilepticus (lasting longer than 5 minutes), which is a medical emergency. The nurse should also ensure safety by loosening restrictive clothing, maintaining airway patency, and turning the child to the side after the seizure to prevent aspiration.
Placing the child prone or restraining movements could cause injury, and hydralazine is an antihypertensive medication, not an anticonvulsant, and therefore inappropriate in this situation.
A nurse is providing discharge teaching to a client who had a myringoplasty about how to decrease trauma and hearing impairment. Which of the following statements should the nurse include in the teaching?
"Clean dried blood in your ear canal with a cotton-tipped applicator."
"Avoid blowing your nose for 1 month after surgery."
"Use petroleum jelly on a cotton ball to plug your ear when shampooing."
"Notify your provider if you have popping or crackling sensations in the affected ear."
The Correct Answer is:
C. "Use petroleum jelly on a cotton ball to plug your ear when shampooing."
Detailed Explanation:
After a myringoplasty (surgical repair of the tympanic membrane), it is essential to keep the ear canal dry to prevent infection and protect the surgical site. Inserting a cotton ball coated with petroleum jelly while showering or shampooing creates a waterproof barrier. Clients should avoid inserting cotton swabs or other objects into the ear. Nose blowing should be done gently after healing, and popping or crackling sensations are normal during recovery as the eardrum adjusts
A nurse is teaching a client who has gambling disorder about the use of cognitive reframing. Which of the following instructions should the nurse give the client?
"Reward yourself for not going to the casino for 1 week."
"Replace thoughts of gambling with positive self-statements."
"Perform deep-breathing exercises when you feel the urge to gamble."
"Use a journal to write down thoughts related to gambling."
The Correct Answer is:
B. "Replace thoughts of gambling with positive self-statements."
Detailed Explanation:
Cognitive reframing is a cognitive-behavioral therapy (CBT) technique that helps clients identify and replace maladaptive or distorted thoughts with more positive and realistic ones. For a client with gambling disorder, this means challenging thoughts like “I can win this time” and replacing them with rational, positive statements such as “Gambling causes me harm” or “I can find healthier ways to cope.”
Rewarding abstinence (A) and journaling (D) are behavioral strategies, while deep breathing (C) is a relaxation technique—none of these directly address cognitive reframing, which focuses specifically on changing thought patterns.
A nurse in an emergency department is caring for a client who has suspected appendicitis. Which of the following actions should the nurse plan to take?
Monitor the client for an elevated RBC count.
Instruct the client to not eat food or drink liquids.
Maintain the client in a supine position.
Administer an enema to the client.
The Correct Answer is:
B. Instruct the client to not eat food or drink liquids.
Detailed Explanation:
When appendicitis is suspected, the client should remain NPO (nothing by mouth) in preparation for possible emergency surgery. Eating or drinking could increase the risk of aspiration during anesthesia. The nurse should also avoid applying heat, giving laxatives, or administering enemas, as these can cause the appendix to rupture. The client is typically positioned in a semi-Fowler’s position to reduce pain and promote drainage if rupture occurs. An elevated WBC, not RBC, count is expected with infection.
A nurse is teaching about organ donation to a client who has a terminal illness. Which of the following client statements indicates an understanding of the teaching?
"I will be kept on life support until my organs are retrieved."
"I am required to be a registered donor before my death."
"I must list the organs I want to donate before my death."
"I need to consult an attorney about donating my organs."
The Correct Answer is:
C. "I must list the organs I want to donate before my death."
Detailed Explanation:
When discussing organ donation, clients should understand that they can specify which organs or tissues they wish to donate before death, either on a donor card, driver’s license, or through an advance directive. This ensures their wishes are honored. Clients are not legally required to be registered donors beforehand; family consent can still authorize donation. An attorney’s involvement is unnecessary, as the process is voluntary and guided by consent laws. Life support is only maintained if needed to preserve organ viability until retrieval, not automatically. Thus, stating that they must list which organs to donate reflects accurate understanding of the process.
A nurse is assessing an older adult client who has depressive disorder. Which of the following findings should the nurse expect?
Reports persistent headaches
Reports increase in sexual desire
Pressured speech
Concrete thinking
The Correct Answer is:
A. Reports persistent headaches.
Detailed Explanation:
In older adults, depression often presents with somatic (physical) symptoms rather than overt emotional complaints. The client may report persistent headaches, fatigue, gastrointestinal discomfort, or generalized pain, which can mask the underlying mood disorder. These physical symptoms are common manifestations of psychological distress in the geriatric population and should prompt screening for depression.
A nurse is assessing an infant who has coarctation of the aorta. Which of the following clinical manifestations should the nurse expect?
Respiratory rate 30/min
Weight loss
Sunken fontanels
Weak femoral pulses
The Correct Answer is:
D. Weak femoral pulses.
Detailed Explanation:
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aortic lumen, which obstructs blood flow from the left ventricle to the lower body. This results in increased blood pressure and bounding pulses in the upper extremities, and weak or absent pulses in the lower extremities, especially the femoral pulses.
A nurse is providing teaching to a client who has neutropenia about preventing foodborne illness. Which of the following instructions should the nurse include?
"Cut damaged areas from fruits and vegetables before consuming."
"Thaw frozen foods at room temperature before cooking."
"Cook raw fish and steak to the well-done stage."
"Reduce your intake of calcium-containing foods."
The Correct Answer is:
C. "Cook raw fish and steak to the well-done stage."
Detailed Explanation:
Clients with neutropenia have a significantly weakened immune system, placing them at high risk for infection, including those caused by foodborne pathogens. The nurse should instruct the client to cook all meats, poultry, and seafood thoroughly—to the well-done stage—to destroy harmful bacteria such as Salmonella, E. coli, and Listeria. Raw or undercooked meats and fish (such as sushi or rare steak) should be avoided entirely.
Additional precautions include avoiding raw fruits and vegetables with damaged skins, unpasteurized dairy products or juices, and foods left at room temperature for more than 2 hours. Thawing foods should be done in the refrigerator, not at room temperature, to prevent bacterial growth. Reducing calcium intake has no relationship to infection prevention.
A nurse is assessing a client who has a complete small bowel obstruction. Which of the following manifestations should the nurse expect? (Select all that apply.)
Urticaria
Distended abdomen
Vomiting
Fluid overload
Obstipation
The Correct Answers are:
B. Distended abdomen, C. Vomiting, and E. Obstipation.
Detailed Explanation:
B. Distended abdomen
A distended abdomen is a classic sign of a small bowel obstruction. Gas and fluid accumulate above the blockage, causing visible abdominal swelling and discomfort. The distention worsens as intestinal contents continue to build up and peristalsis attempts to move them past the obstruction unsuccessfully.
C. Vomiting
Vomiting occurs as the intestinal contents cannot pass through the obstruction. In a small bowel obstruction, the vomiting is typically frequent and projectile, often containing bile or partially digested food. The severity increases the higher the obstruction is located in the small intestine.
E. Obstipation
Obstipation—complete absence of stool and flatus—is a hallmark of a complete bowel obstruction. This happens when the blockage prevents any intestinal contents from moving forward, indicating total cessation of intestinal motility below the obstruction.
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