ATI Casal 1 Practice Assessment: Questions & Solutions
A nurse is caring for a patient with tuberculosis. Which of the following
actions should the nurse take? (Select all that apply) Right Ans - Place the
client in a room with a negative pressure airflow (Meets requirements of
airbone precautions)
Wear gloves when assisting the client with oral care (Wear gloves whenever
hands make contact with bodily fluids, meets requirements of standard
precautions)
The nurse should wear an N95 respirator during client care (to meet
requirements of airborne precautions)
Use antimicrobial hand sanitizer for routine hand hygiene (nurse should also
wash her hands with soap and water when hands have visible soiling)
A nurse is caring for a patient who has a prescription for 5 units of regular
insulin and 10 units of NPH insulin to mix together and administer SUBQ.
Determine the correct order of steps Right Ans - The nurse should first
inject air into the vial of NPH without touching the needle to the solution.
Next, the nurse should inject air into the regular the vial of regular insulin, and
then withdraw the correct amount of the regular insulin. Finally, the nurse
should insert the needle into the NPH solution and withdraw the correct
amount of NPH insulin.
A nurse is completing an admission assessment for a client who reports
vomiting and diarrhea for the past 3 days. Which of the following should the
nurse expect? Right Ans - Rapid heart rate (tachycardia indicates fluid-
volume deficit, which is an expected finding for this case)
A nurse is administering IV fluid to an older adult. The nurse should perform
which priority assessment to monitor for adverse effects? Right Ans -
Auscultate lung sounds (the PRIORITY assessment the nurse should make
when using the airway, breathing, circulation approach to client care is
auscultating the lung sounds to monitor for fluid-volume excess, a
complication of IV therapy. Manifestations of fluid volume excess include
moist crackles, heard in lung fields, dyspnea, & shortness of breath)
The nurse is admitting a client who has an abdominal wound with a large
amount of purulent drainage. Which type of transmission precautions should
the nurse initiate? Right Ans - Contact precautions (Major wound
, infections require contact precautions, which means the nurse should admit
the client to a private room. All caregivers should wear a gown and gloves
during direct contact with patient)
A nurse is reviewing practice guidelines with a group of newly licensed
nurses. Which of the following interventions is within the RN scope of
practice? Right Ans - Initiate an enteral feeding through a gastrostomy tube
(It is within the RN scope of practice to initiate enteral feedings through
nasoenteric, gastrostomy, and jejunostomy tube)
A nurse is caring for a patient with a prescription for wound irrigation. Which
action should the nurse take? Right Ans - Cleanse the wound from the
center outward (prevent introduction of micro-organisms from the outer skin
surface)
A nurse is caring for a patient who reports pain. When documenting the
quality of the patients pain which statement made by the patient should the
nurse record? Right Ans - "The pain is like a dull ache in my stomach"
(Client is describing the quality of pain, which is how the pain feels in her own
words)
A nurse is caring for a patient who reports experiencing difficulty falling
asleep. Which measure should the nurse recommend? Right Ans - Use
progressive relaxation techniques at bedtime (promotes sleep by decreasing
stress and reducing muscle tension)
A nurse is preparing to administer multiple medications to a client who has an
enteral feeding tube. Which action should the nurse take? Right Ans - Flush
the tube with 15 mL of sterile water (The nurse should flush the tube with 15-
30 mL of sterile water before administration and between each medication.
The nurse should flush the feeding tube with 30 to 60 mL of sterile water
following the administration of the last medication)
A nurse is administering an otic medication to an older adult client. Which
action should the nurse take to ensure that the medication reaches the inner
ear? Right Ans - Press gently on the tragus of of the ear (helps medication
reach inner ear)
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