ATI Proctored Fundamentals Exam
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
"Are you able to help with your hygiene care?"
A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?
"Client was found lying on floor."
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
"I am available to talk if you should change your mind."
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
"I'll check the wires and cables on my TV to make sure they are in good working order."
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
"Is your pain sharp or dull?"
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
"The pain is like a dull ache in my stomach."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
"This is a difficult time, but we are helping each other through this."
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
"Use the complete name of the medication magnesium sulfate."
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
"We can talk about advance directives, and I can also give you some brochures about them."
A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?
"We need to document the exact medication you were taking because you might be allergic to it."
A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?
"We will apply oxygen through a tube in your nose"
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"When descending stair, I will first shift my weight to my right leg."
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?
"You should have a fecal occult blood test every year."
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?
1. Ask the client if he can bear weight. 2. Position the chair on the left side of the bed. 3. Have the client sit and dangle his feet at the bedside. 4. Use the stand-and-pivot technique to move the client to the chair.
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
107 mL/hr
A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for primary hypertension?
A client who has an elevated LDL
According to the principals of triage, which of the following clients requires immediate nursing intervention during a mass casualty disaster?
A middle aged adult client who has a sucking chest wound
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with her documentation.
A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?
Abdominal Cramping
A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?
Administer pain medication 45 minutes before changing the client's dressing
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
Air into NPH Air into Regular Draw up Regular Draw up NPH
A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?
Airborne
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?
Albumin Level of 3g/dL
A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
An uneven shape
A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?
An x-ray shows the end of the tube above the pylorus
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel?
Arrange the lunch tray for a client with a hip fracture
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage.
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Assess the client for orthostatic hypotension
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
Assist the client to an upright position.
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
Auscultate Lung Sounds
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
Bladder scan shows 525mL of urine
A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Breath Sounds
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Calf Swelling
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Check the client for injuries
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
Clean sutures along the incision site.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the wound from the center outward.
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received during hospitalization.
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
Contact Precautions
A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Decrease in Heart Rate
A nurse is evaluating an client who is taking chlorpromazine. Which of the following findings indicates that the medication is effective?
Decreased Hallucinations
A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
Droplet
A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
Elevate the head of the client's bed
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
Erythema on pressure points
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
Evaluate Electrolytes
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 mL of sterile water.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client wears a mask when outside her room if there is construction in the area.
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
Narrowed Arterial Lumen
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
Notify the nursing manager
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative-pressure airflow.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 meq/L
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
Practice Sessions
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Pressing gently on the tragus of the client's ear.
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
Pupil Clarity Visual Fields Visual Acuity
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
Rapid Heart Rate
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Regulate oxygen via nasal cannula at a flow rate no more than 6 L/min
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
Remove the stockings at least once per shift.
A nurse assessing a client after administering epinephrine for an anaphylactic reaction. The nurse should monitor the client for with of the following adverse effects of this medication?
Reports of chest pain
A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?
Second intercostal space at the left sternal boarder
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen.
A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
Semi-Fowler's
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
Situation, Background, Assessment, and Recommendation (SBAR)
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
Skin Blanching
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigant used from the client's urine output.
A nurse is caring for a client who requires an alternative communication method. Which of the following is an appropriate intervention by the nurse?
Suggest that a postoperative laryngectomy client use a pad and pencil to write out her requests
A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?
Swelling and coolness are observed at the IV site
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
Tell the client to keep the head of the bed elevated at least 30 degrees.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of her body.
A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
The family member washed out the feeding bag with warm water once every 24 hours.
A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
The nurse opens the sterile field on a wet surface
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
Thread the IV catheter so that the hub rests at the insertion site.
A nurse is caring for a client who is receiving oxytocin for a labor induction and notes frequent variable decelerations. Which of the following actions should the nurse take first?
Turn the client on her left side
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use tracheostomy covers when outdoors
A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
Walking Briskly
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
Wash her hands before and after contact with the client
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
Wrap blankets around all four side rails
A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?
▪️A 16 year old client who is married. ▪️A 27 year old who has schizophrenia. ▪️An adoptive parent who brings in his 8 year old son. ▪️A 17 year old mother who brings in her toddler.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
▪️Assist the client with a partial bed bath ▪️Measure the client's BP after the nurse administers an antihypertensive medication ▪️Use a communication board to ask what the client wants for lunch
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
▪️Obtain the pronouncement of death from the provider ▪️Remove tubes and indwelling lines ▪️Wash the client's body ▪️Ask the client's family members if they would like to view the body ▪️Place a name tag on the body
