Exam (elaborations)
ATI RN FUNDAMENTALS PRACTICE TESTS A & B
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ATI RN FUNDAMENTALS PRACTICE TESTS A & B
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ATI RN FUNDAMENTALS PRACTICE TESTS A & BA 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?
"I am having mild pain"
"The pain is like a dull ache in my stomach"
"I notice that the pain gets worse after I eat"
"The pain makes me feel nauseous" - Answers-"The pain is like a dull ache in my
stomach"
A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse
confirms the presence of the fire, which of the following actions should the nurse take
next?
Activate the emergency fire alarm
Extinguish the fire
Evacuate the client
Confine the fire - Answers-Evacuate the client
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter.
Which of the following findings at the IV site should the nurse identify as indicating
infiltration?
Purulent exudate
Warmth
Skin blanching
Bleeding - Answers-Skin blanching
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 the stairs, I will first shift my weight to my right leg"
"I should place my crutches 12 inches in front and to the side of each foot"
"As I sit down, I will hold one crutch in each hand"
"I will make sure the shoulder rests are snug against my armpits" - Answers-"When
descending the stairs, I will first shift my weight to my right leg"
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?
Rinse the feeding back with water between feedings
Tell the client to keep the head of the bed elevated at least 30 degrees
Make sure the enteral formula is at room temperature
Wipe the top of the formula can with alcohol - Answers-Tell the client to keep the head
of the bed elevated at least 30 degrees
,A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by
mouth every day". Which of the following components of the prescription should the
nurse verify with the provider?
Medication name
Route of administration
Medication dose
Frequency of administration - Answers-Medication dose
A nurse is caring for a client who has recently started using a behind the ear hearing
aid. Which of the following statements should the nurse identify as an indication that the
client understands the use of this assistive device?
"This type of hearing aid does not allow for fine tuning of volume"
"I shouldn't have trouble keeping the hearing aid in place during exercise"
"I expect to hear a whistling sound when I first insert the hearing aid"
"I will be sure to remove my hearing aid before taking a shower" - Answers-"I will be
sure to remove my hearing aid before taking a shower"
A nurse enters a client's room and finds her on the floor. The client's roommate reports
that the client was trying to get out of bed and fell over the side rail onto the floor. Which
of the following statements should the nurse document about this incident?
"Incident report completed"
"Client climbed over the side rails"
"Client found lying on the floor"
"Client was trying to get out of bed" - Answers-"Client found lying on the floor"
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?
Seal unused medications from the facility in a plastic bag
Evaluate the client's ability to self administer medications
Report an identified discrepancy to The Joint Commission
Compare prescriptions with medications the client received while at the facility -
Answers-Compare prescriptions with medications the client received while at the facility
A nurse is completing an admission assessment for a client who reports vomiting and
diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Neck vein distention
Urine specific gravity 1.010
Rapid Heart rate
Blood pressure 144/82 mmHg - Answers-Rapid heart rate
A nurse has accepted a verbal prescription for "thee 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?
.3 mg
0.3 mg
0.30 mg
, 3/10 mg - Answers-0.3 mg
A nurse is preparing a heparin infusion for a client who was admitted to the facility with
deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium
chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the
infusion pump? - Answers-8 ml/hour
A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
Wear sterile gloves when removing the old dressing
Warm the irrigation solution to 40.5 C (105 F)
Cleanse the wound from the center outward
Use a 20 ml syringe to irrigate the wound - Answers-Cleanse the wound from the center
outward
A nurse is caring for a client who requires an informed consent for a surgical procedure.
Which of the following actions is the nurse's responsibility?
Describe the procedure to the client
Witness the client's signature on the consent form
Inform the client of alternatives to the procedure
Tell the client which team members will assist with the procedure - Answers-Witness the
client's signature on the consent form
A nurse is planning an educational program for a group of older adults at a senior living
center. Which of the following recommendations should the nurse include?
"You should have an eye examination every 2 years"
"You should receive a tetanus booster every 5 years"
"You should receive a shingles vaccine when you are 70 years old"
"You should receive a pneumococcal vaccine when you are 65 years old" - Answers-
"You should receive a pneumococcal vaccine when you are 65 years old"
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?
Ask the client to consider a direct donation
Withhold the blood transfusion
Request a consultation with the ethics committee
Ask the client's family to intervene - Answers-Withhold the blood transfusion
A nurse is admitting a client who has rubella. Which of the following types of
transmission based precautions should the nurse initiate?
droplet
airborne
contact
protective environment - Answers-droplet
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