ATI Fundamentals Content Series Detailed Questions and Verified Answers Exam 2026 100% Pass

ATI Fundamentals Content Series Detailed Questions and Verified Answers Exam 2026 100% Pass A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients - Correct Ans B Ensuring that health care providers comply with regulations State licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations. A. Review committees responsible C. The Joint Commission D. The U.S. Food and Drug Administration A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? Select all that apply. A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid - Correct Ans-B, E PPO, Long-term care insurance, EPO are all privately funded A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training in surgical treatments for obesity ATI ATI D. Educating acute care nurses about postoperative complications related to obesity - Correct Ans-A. Obesity screenings at office visits is an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings. B. REHAB - Restorative Care C. SPECIALIZED - Tertiary Care D. ACUTE - Secondary Care A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? Select all that apply. A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care - Correct Ans-A, B, C Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units, an oncology treatment center, and a burn center. D, E Cardiac rehabilitation and home health care are examples of restorative care. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? Select all that apply. A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - Correct Ans-A, B, D Restorative health care involves intermediate follow-up care for restoring health and promoting self-care. Home health care, rehabilitation facilities, and skilled nursing facilities are types of restorative health care. C, E Diagnostic centers Secondary health care includes the diagnosis and treatment of acute injury or illness. Diagnostic centers are a type of secondary health care. ATI ATI A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - Correct Ans-D. Occupational therapist The nurse should identify that an occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities. A certified nursing assistant can help the client with feeding but does not typically procure adaptive devices for the client. A. A social worker can coordinate community services to help the client, but not specifically with self-feeding devices. B. A certified nursing assistant can help the client with feeding but does not typically procure adaptive devices for the client. C. A registered dietitian can help with educating the client about meeting nutritional needs but cannot help with the client's physical limitations. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? Select all that apply. A. A client who has terminal cancer requests hospice care in the home B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer." - Correct Ans-A, B, D The nurse should initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client, care for community resources available for clients, and to assist the client in obtaining medical equipment for use after discharge C The nurse should initiate a referral for spiritual support staff if a client requests specific religious sacraments or prayers. E The nurse should provide client teaching for concerns regarding the use of a nebulizer. If additional information is needed, initiate a referral for a respiratory therapist. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? Select all that apply. ATI ATI A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - Correct Ans-A, C, D The provider, pharmacist, and RN must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions. B It is not within the scope of a certified nursing assistant's duties to counsel a client about medications. E. Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist, it is not within this therapist's scope of practice to counsel the client about medications prescribed by the provider. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? Select all that apply. A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist E. Physical therapist - Correct Ans-C, D The nurse should identify that a speech-language pathologist and an occupational therapist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties. A. A social worker can coordinate community services to help the client, but not specifically with dysphagia. B. A certified nursing assistant can help the client with feeding but cannot assess and treat dysphagia. E. A physical therapist can assist clients who have motor challenges to improve abilities with self-care and work but cannot assess and treat dysphagia. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? Select all that apply. A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - Correct Ans-A, B, C, E ATI ATI The nurse should identify that it is within the range of function for a CNA to provide basic care to clients, such as bathing, assisting with ambulation, assisting with toileting, and measuring and recording vital signs. D. Determining pain level is a task that requires the assessment skills of licensed personnel (nurses). It is outside the range of function for a CNA. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A.Fidelity B. Autonomy C. Justice D. Nonmaleficence - Correct Ans-B. Autonomy The nurse identifies that in this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them. This is an example of autonomy. A. Fidelity is the fulfillment of promises. The nurse has not made any promises; this is the client's decision. C. Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur whether or not the client has surgery. However, because they choose not to, this principle does not apply. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence - Correct Ans-D. Beneficence The nurse should identify that beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client. A. Fidelity is the fulfillment of promises. Unless the nurse has specifically promised the client a pain-free recovery, which is unlikely, this principle does not apply to this action. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, the nurse is delivering responsible client care. This principle does not apply. ATI ATI C. Justice is fairness in care delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - Correct Ans-C. Justice The nurse should identify that justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. A. Fidelity is the fulfillment of promises. Because donor organs are a scarce resource compared with the numbers of potential recipients who need them, no one can promise anyone an organ. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved with the qualifications for organ recipients. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - Correct Ans-D. Nonmaleficence The nurse should identify that nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle. A. Fidelity is the fulfillment of promises. The nurse is not addressing a specific promise when they determine the appropriateness of a prescription for the client. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved when the nurse questions the client's prescription. ATI ATI C. Justice is fairness in care delivery and in the use of resources. In this situation, the nurse is delivering responsible client care and is not assessing available resources. This principle does not apply. A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form. - Correct Ans-C. The nurse should identify that making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. A, B, D. Delivering client care while showing signs of a substance use disorder, a nurse who threatens to restrain a client has committed assault, the selection of a person to make health care decisions on a client's behalf is a legal issue, not an ethical dilemma. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used the next time the urinal is used improperly. Which of the following torts is the AP Committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy - Correct Ans-A. Assault When recognizing cues the nurse should identity that the AP is threatening the client; therefore, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive. B. Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. C. Unless the AP restrains the client, there is no false imprisonment involved. D. Invasion of privacy involves disclosing information about a client to an unauthorized individual. Isabelle is preparing to obtain a consent form from Mr. Snyder who is scheduled for surgery. Leo has asked Isabelle what their duties are as a nurse. Which of the following statements by Isabelle reflect a correct understanding of the role of the nurse when obtaining consent? ATI ATI Select all that apply. A. "I should make sure that the provider included the necessary information." B. "I should make sure the client understands the information." C. "I should witness the client signing the consent form." D. "I should discuss other options for treatment with the client." E. "I should notify the provider if the client has questions about the procedure." - Correct Ans-A, B, C, E When taking action, the nurse should make sure that the provider included the necessary information; make sure the client understands the information, witness the client signing the consent form and notify the provider if the client has questions about the procedure. D. The provider should discuss other treatment options with the client. A nurse notes that an oncoming nurse smells of alcohol and seems unsteady. Which of the following actions should the nurse take? A. Report the oncoming nurse to the board of nursing. B. Confront the oncoming nurse. C. Notify the oncoming supervisor. D. Ask an assistive personnel (AP) if they smelled alcohol on the oncoming nurse's breath. - Correct Ans-C. The nurse's duty is to protect client safety. The nurse should report the observation to the oncoming supervisor whose duty is to ensure that a thorough investigation occurs and if the facts indicate the nurse reported to work after drinking alcohol, reporting the nurse to the state board of nursing. A. The nurse should report the observation to the oncoming supervisor whose duty is to ensure that a thorough investigation occurs and if the facts indicate the nurse reported to work after drinking alcohol, reporting the nurse to the state board of nursing. B, The nurse should avoid confronting the oncoming nurse who might become hostile. D. The nurse should also avoid involving another person on the shift such as the AP. A nurse is providing preoperative teaching for a client who is scheduled for surgery the next week. The client tells the nurse "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client indicates an understanding of advance directives? A. "I'd rather have my brother make my decisions for me, but I know it must be my spouse." B. "I know they won't go ahead with the surgery unless I fill out the form." C. "I plan to tell them I don't want to be kept on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it to the hospital." - Correct Ans-C. ATI ATI The hospital staff cannot refuse care based on the lack of advance directives. The client has the right to decide and specify which medical procedures they want when a life threatening situation arises. A. When analyzing cures, the nurse should recognize that the client can designate any competent adult to be their health care proxy. It does not have to be their spouse. B. The hospital staff cannot refuse care based on the lack of advance directives. The client has the right to decide and specify which medical procedures they want when a life-threatening situation arises. D. However, they should give his primary care provider a copy of the document for their records. A nurse is assigned to care a client who has tuberculosis. The nurse understands that the intent of this tracking is which of the following? A. To track information that poses a threat to the public. B. To provide appropriate antibiotics at no cost the client. C. To assist the Joint Commission with its goals for client safety. D. To aid in obtaining personal protective equipment for the facility. - Correct Ans-A. The Centers of Disease and Infection Control prevention monitors certain illness and disease that can pose a threat to the public. The purpose of this activity is to limit the spread of the diseases. B, C, D The Centers of Disease and Infection Control prevention monitors certain illness and disease that can pose a threat to the public. The purpose of this activity is to limit the spread of the diseases. A nurse is providing teaching with a newly licensed nurse about incorporating culturally responsive nursing care. Which of the following statements by the newly licensed nurse indicates understanding? A. "It is a form of client ethnocentrism." B. "It involves being knowledgeable about various cultures." C. "It involves the delivery of care that includes the client's beliefs." D. "It is the examination of the nurse's personal attitude." - Correct Ans-C. Culturally responsive nursing care involves the delivery of care that considers a client's cultural beliefs that could affect their well-being. A. Cultural imposition is a form of ethnocentrism. B. Cultural sensitivity is the term used to describe being knowledgeable about various cultures. D. Cultural awareness is self-awareness for the nurse to identify potential bias. A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse take? ATI ATI Select all that apply. A. Using a facility approved medical interpreter B. Determining the client's understanding several times during the conversation C. Looking at the interpreter when asking the client questions D. Using medical terms during the conversation E. Asking one question at a time - Correct Ans-A, B, E When taking actions, the nurse should use a facility approved medical interpreter to ensure accuracy of the medical information and maintain client confidentiality. Determining client understanding throughout the conversation ensures the client comprehends the information and the nurse will know how to direct the conversation. Asking one question at a time and allowing the client time to respond will promote effective communication between the client and the nurse or interpreter A nurse is using the FICA screening tool to gather more data about a client's interfaith needs. Which of the following questions should the nurse ask when using the tool? A. "What gives you a sense of purpose?" B. "Who inspires you?" C. "How has this condition affected you?" D. "Do you have a communication barrier?" - Correct Ans-A. When using the FICA screening tool, the nurse should ask open-ended questions to gather more information about the client's interfaith needs. The nurse should ask questions to check the client's faith, implications/influence, community, and address. "What gives you a sense of purpose?" is an appropriate question to ask because this is addressing the client's faith B, C, D Are not appropriate questions to ask because they will not address the client's interfaith needs A nurse is caring for a client who tells the nurse that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. What actions should the nurse take? - Correct Ans-When taking actions, the nurse should demonstrate culturally responsive care and show respect for the client's religious beliefs. The nurse should have the provider discuss the necessity for a blood transfusion, alternatives to the use of blood products, and allow the client to make an informed decision. A nurse enters the room of a client who is reading from a religious book. The client begins to cry and asks to be left alone. What actions should the nurse take? - Correct Ans-When taking actions, the nurse should demonstrate culturally responsive care and show respect to the client by providing time for the client to be alone. The nurse should close the door to the client's room and give the client time without interruption to pray and reflect. After giving the client quiet, uninterrupted time, the nurse can establish presence with the client by sitting, listening, showing acceptance, and supporting the ATI ATI client. The nurse can offer to contact a spiritual care provider to provide the client with spiritual support if needed. A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? Select all that apply. A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing. - Correct Ans-B,D It takes 15 seconds to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands. A. The APs should apply alcohol rubs to dry hands. When washing hands with soap and water, the Aps should wet the hands first before applying soap for handwashing. C. The APs should use warm not hot water to minimize the removal of protective skin oils. E. The APs should dry their hands with a clean paper towel. This helps prevent chapped skin. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D.Keep a box of facial tissues nearby for the client to use during the dressing change. - Correct Ans-C Placing a mask on the client prevents contamination of the surgical wound during the dressing change A. It would be difficult for to maintain a sterile field away from the bedside. But more important, this might not have any effect on the transmission of some micro-organisms. B. The client might be unable to refrain from coughing and sneezing during the dressing change. D. Keeping tissues close by for the client to use still allows contamination of the surgical wound. ATI ATI A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? Select all that apply. A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field. - Correct Ans-B, C, D Fluid permeation of the sterile drape or barrier contaminates the field. Prolonged exposure to air contaminates a sterile field. Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field A. As long as the provider has not reached over the sterile field (by placing the instrument on a near portion of the field), the field remains sterile. E. The 1-inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? Select all that apply. A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe appropriately placed on the sterile field E. One gloved hand with the other gloved hand - Correct Ans-C, D, E C. The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves. D. Any sterile objects dropped onto the sterile field during the setup are sterile. Touch the syringe with sterile gloves. E. One sterile gloved hand may touch the other sterile gloved hand because both are sterile. A. A bottle of sterile solution is sterile on the inside and non-sterile on the outside. Place the solution in a sterile container on the field before putting on sterile gloves B. The 1-inch border at the outer edge of the sterile field is not sterile. Do not touch it with sterile gloves. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? ATI ATI A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body - Correct Ans-D The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it. A. The flap closest to the body is the innermost flap and the last one to unfold. B, C. Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur. Prodromal Convalescence Incubation Illness - Correct Ans-Incubation Prodromal Illness Convalescence When taking actions to review the stages of infection in order, the nurse will first review the incubation stage, the interval between the pathogen entering the body and the presentation of manifestations. The nurse will then review the prodromal stage, the interval from onset of general manifestations to more distinct findings. The nurse will then review the illness stage, in which manifestations specific to the infection occur. The nurse will discuss last the convalescence stage, in which acute findings disappear and total recovery occurs. A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is localized or systemic. Fever Malaise Edema Pain or tenderness Increased heart rate and respiratory rate - Correct Ans-Localized: Edema, Pain or tenderness Systemic: Fever, Malaise, Increased heart rate and respiratory rate ATI ATI A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest? Select all that apply. A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions. - Correct Ans-B, C, E When generating solutions for a client who has pertussis, the nurse should suggest using droplet precautions when caring for this client, including wearing a mask when within 3 feet when caring for the client to protect against inhalation of small droplets and placing a surgical mask on the client when transporting them to contain respiratory droplets. The nurse should also suggest wearing a gown when care may involve contamination from respiratory secretions. The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required. Tuberculosis SARS-CoV-2 (COVID 19) Influenza C. difficile MRSA - Correct Ans-Contact: C. difficile and MRSA Droplet: Influenza Airborne: Tuberculosis and SARS-CoV-2 A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? Select all that apply. A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. - Correct Ans-C, D, E C. Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. Nonskid footwear keeps the client from slipping. ATI ATI E. A fall-risk assessment serves as the basis for a plan of care that can then individualize for the client. A. The nurse should identify that restraining the client places a liability risk for false imprisonment. B. Ensuring full side rails for this client puts the client at risk for a fall because they might attempt to climb over the rails to get out of bed. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession. - Correct Ans-A. The nurse should identify that the first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures. B. The nurse should educate the client and family about fall risk factors so they can help promote client safety, but this is not the priority action. C. The nurse should eliminate safety hazards from the client's environment to help reduce the risk for falls, but this is not the priority action. D. Aids, such as eyeglasses, hearing aids, canes, and walkers should be accessible to reduce the client's risk for falls, but this is not the priority action. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway." - Correct Ans-B. The nurse should Identify that during a seizure, the client should not be left alone, and the call light system should be activated to summon assistance. A. During a seizure, the client should be placed in a side-lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. C. The nurse should note the time the seizure begins and track how long the seizure lasts. D. Place nothing in the client's mouth except an oral airway, if necessary. A tongue blade can cause injury and airway obstruction A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? ATI ATI A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. - Correct Ans-C The nurse should identify that the greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire. A. Although extinguishing the fire is part of the protocol for responding to a fire, it is not the priority action. B. Activating the fire alarm is part of the protocol for responding to a fire, however, it is not the priority action. D. Although containing the fire by closing doors and windows is part of the protocol for responding to a fire, it is not the priority action. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? Select all that apply. A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances - Correct Ans-B, C, E When taking action, the nurse should instruct that right supervision and evaluation, right direction and communication, and right circumstances are included in the five rights of delegation. Right task and right person are also included in the five rights of delegation. The five rights of delegation are used to ensure client care is delegated in a safe and effective manner. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Nursing supervisor B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP) - Correct Ans-B When taking actions, the nurse manager should identify that a client who is postoperative following thoracic surgery requires the professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care A nurse is delegating the ambulation of a client who had a knee arthroplasty 2 days ago to an AP. Which of the following information should the nurse share with the AP? Select all that apply. ATI ATI A. The client's roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning. - Correct Ans-B, C, D When taking actions, the nurse should provide right direction and communication to ensure the AP can complete this assignment safely. The nurse should share information with the AP to make sure the client wears stockings and slippers and uses a front wheeled walker while ambulating. The AP should know that the client might be feeling the effects of the pain medication A nurse on a medical-surgical unit has received change-of-shift report on five clients. Understanding that a PN can perform each of the following tasks, sort the tasks the nurse should assign to the AP or the PN. Assist with updating the plan of care for a client who is postoperative Reinforce teaching with a client who is learning to walk using a quad cane Reapply a condom catheter for a client who has urinary incontinence Apply a sterile dressing to a pressure injury Perform postmortem care for a client who has died - Correct Ans-AP Reapply a condom catheter for a client who has urinary incontinence Perform postmortem care for a client who has died PN Assist with updating the plan of care for a client who is postoperative Reinforce teaching with a client who is learning to walk using a quad cane Apply a sterile dressing to a pressure injury A charge nurse is assigning client care to an RN and a PN. Understanding that an RN can perform each of the following tasks, match the tasks the nurse should assign to the RN or the PN Creating a plan of care for a client who is recovering following a stroke Assessing a pressure injury on a client who is on bed rest Providing nasopharyngeal suctioning for a client who has pneumonia Teaching a client who has asthma to use a metered-dose inhaler Administer enteral feeding to a client who has a nasogastric tube Inserting a urinary catheter for a client who has urinary retention. - Correct Ans-RN Creating a plan of care for a client who is recovering following a stroke Assessing a pressure injury on a client who is on bed rest Teaching a client who has asthma to use a metered-dose inhaler PN ATI ATI Providing nasopharyngeal suctioning for a client who has pneumonia Administer enteral feeding to a client who has a nasogastric tube Inserting a urinary catheter for a client who has urinary retention. A charge nurse is discussing the levels of critical thinking with a newly licensed nurse. Sort the following interventions into basic, complex, or commitment critical thinking levels. A nurse follows a facility's procedure manual to change an IV dressing. A nurse repositions a client's arm to improve the infusion of an IV. A nurse increases an IV rate on a client who has hypotension. - Correct Ans Commitment A nurse increases an IV rate on a client who has hypotension. Basic A nurse follows a facility's procedure manual to change an IV dressing. Complex A nurse repositions a client's arm to improve the infusion of an IV. A charge nurse is discussing the components of critical thinking with a newly licensed nurse. Sort the following situations into knowledge, experience, or competence components of critical thinking. A nurse uses an electronic database to gather information about a medication before administering it to a client. A nurse has been working with clients who have diabetes mellitus for over 5 years. A nurse uses the nursing process when caring for a client who has hypoglycemia. - Correct Ans-Experience A nurse has been working with clients who have diabetes mellitus for over 5 years. Competence A nurse uses the nursing process when caring for a client who has hypoglycemia. Knowledge A nurse uses an electronic database to gather information about a medication before administering it to a client. A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. Creativity Risk-taking Fairness Perseverance Responsibility ATI ATI Caring for a client in a nonjudgmental manner. Checking a client's medical record for allergies before administering a medication. Taking a calculated chance to find a solution to a client's problem Using imagination to find a unique solution to solve a client's problem. Continuing to work to solve a problem for a client until there is a solution. - Correct Ans Creativity Using imagination to find a unique solution to solve a client's problem. Risk-taking Taking a calculated chance to find a solution to a client's problem. Fairness Caring for a client in a nonjudgmental manner. Perseverance Continuing to work to solve a problem for a client until there is a solution. Responsibility Checking a client's medical record for allergies before administering a medication. A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. Confidence Integrity Humility Discipline Curiosity Showing honesty when caring for clients. Using a head-to-toe approach to conduct a physical examination on a client. Speaking with certainty to a client when instructing them about a new diet. Asking questions to obtain more information about a client's problem. Identifying limitations of oneself when dealing with a clinical situation. - Correct Ans Confidence Speaking with certainty to a client when instructing them about a new diet. Integrity Showing honesty when caring for clients. Humility Identifying limitations of oneself when dealing with a clinical situation. Discipline Using a head-to-toe approach to conduct a physical examination on a client. ATI ATI Curiosity Asking questions to obtain more information about a client's problem. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? Select all that apply. A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs. F. Organize client data using a concept map. - Correct Ans-A, B, C, F When taking actions to improve critical thinking, the newly licensed nurse should find a mentor to discuss client care and gain knowledge from the mentor's experience. Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking skills. Learning new information about evidence-based practice improves the nurse's ability to think critically. Creating a concept map improves critical thinking skills by organizing and connecting client data to identify possible clinical patterns and relationships. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting time to establishing an occupation D. Finding oneself "sandwiched" between and being responsible for two generations - Correct Ans-C The nurse should identify that exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult. A. Active involvement in the next generation is a developmental task for middle adults. B. Adjusting to major role changes associated with loss is a developmental task for older adults. D. Assuming responsibility for the previous as well as the next generation is a developmental task for middle adults. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? ATI ATI A. "I have my own apartment now, but it's not easy living away from my guardians." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My partner is pregnant, and I don't think I have what it takes to be a good parent." - Correct Ans-C. The nurse should identify that when using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage. According to Erikson, it is a task of adolescence to develop identity vs. role confusion. The nurse should recognize this young adult is still struggling with this task and needs assistance in working through that dilemma. A. Living away from home and establishing independent living is nonurgent because it is an expected challenge during a young adulthood. There is another statement to identify as the priority. B. Transitioning from being single to being a member of a new family is nonurgent because it is an expected challenge during young adulthood. There is another statement to identify as the priority. D. Considering childbearing and parenting is nonurgent because it is an expected challenge during young adulthood. There is another statement to identify as the priority. A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? Select all that apply. A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio - Correct Ans-A, C, D The nurse should identify that the CDC recommends an annual influenza immunization, a booster dose of pertussis vaccine, and a booster dose of diphtheria and ongoing booster doses of tetanus during adulthood. B, E The CDC recommends obtaining the measles, mumps, rubella, and polio vaccines routinely during childhood. The series can be administered during adulthood for individuals who meet certain criteria. A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "I will just go to an urgent care center for my routine medical care." ATI ATI D. "There's no reason to seek help if I am feeling stressed because it's just part of life." - Correct Ans-B. The nurse should identify that despite being in relatively good health, young adult clients should plan to participate in routine screenings and health care visits. A.For protection against a wide variety of communicable illnesses, encourage adults to obtain CDC-recommended immunizations throughout the lifespan. C. Urgent care centers offer limited services, typically for acute injuries or problems that cannot wait until a primary care provider is available. Encourage clients to establish a relationship with a primary care provider to consult for nonurgent health problems. D. Although it is true that stress is inevitable, chronic stress can lead to severe health alterations. Young adults who have stress that is recurrent, or escalating should seek medical care. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? Select all that apply. A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home. - Correct Ans-B, C, D The nurse should encourage the client to wear a helmet while skiing to reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports. Therefore, this is an age-appropriate recommendation for this developmental group. The nurse should remind the client to install a carbon monoxide detector in the home. This is an essential safety precaution for young adults as well as for all other developmental stages. The nurse should warn the client to secure firearms in a safe location to reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group. A. Although bath rails and grab bars add a measure of safety to bathing activities, this recommendation addresses health risks common to the older adult population due to their risk for falls. E. Throw rugs can pose a safety hazard, this recommendation addresses health risks common to the older adult population due to their risk for falls. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? ATI ATI Select all that apply. A. Metabolism B. Ability to hear low-pitched sounds C. Subcutaneous fat D. Far vision E. Glomerular filtration - Correct Ans-A, C, E The nurse should expect metabolism to decline, causing weight gain during middle adulthood. In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates. B. The nurse should expect a decline in the ability to hear high-pitched sounds during middle adulthood. D. The nurse should expect a decline in near vision (presbyopia) during middle adulthood. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates their behavior after a social interaction. B. The client states they are learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation. - Correct Ans-D. The nurse should identify that Erickson's task for a middle adult is generativity vs. stagnation. The nurse should include showing concern for the next generation as an example for this age group. A. Evaluating behavior after a social interaction is a developmental task that begins during the preschool years. B. Learning to trust others is a developmental task of infancy during Erickson's trust vs. mistrust stage. C. Finding meaningful friendships is a developmental task for school-aged children. A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? Select all that apply. A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performance C. Welcome opportunities to be creative and productive. ATI ATI D. Commit to finding friendship and companionship. E. Become involved with community issues and activities. - Correct Ans-B, C, E Psychosocially healthy middle adults strive to do well in their environment as part of achieving Erikson's stage of generativity vs. stagnation. Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. Psychosocially healthy middle adults work to contribute to future generations through community involvement and parenting as part of achieving Erikson's stage of generativity vs. stagnation. A. Identify acceptance of diminished strength and increased dependence as a developmental task for older adulthood. D. Identify seeking and forming friendships as a developmental task of young adulthood. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my child expects me to relive my parenting days." - Correct Ans-B. When using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, developing intimacy vs. isolation is a task of young adulthood. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others. A. Adjusting to and caring for aging parents is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority C. Contributing to the community is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority. D. Questioning the ability to contribute to future generations is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority. A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? Select all that apply. ATI ATI A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders - Correct Ans-A, C, D, E The nurse should recommend middle adult clients have an eye examination every 1 to 3 years to screen for glaucoma and other disorders. Middle adults should have a DXA scan to screen for osteoporosis, obtain adequate protein, and consume more fresh fruits, vegetables and whole grains. The nurse should also recommend screening for anxiety and depression during middle adulthood. B. The nurse should recommend that middle adult clients, especially females, increase intake of vitamin D and calcium to prevent osteoporosis. A nurse is obtaining a health history from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? Select all that apply. A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity - Correct Ans-B, D, E The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL. A. The nurse should identify that physiological changes that occur with aging can include decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which can cause wrinkles and dry, thin, transparent skin. C. Other physiological changes that occur with aging can include decreased saliva production, making xerostomia (dry mouth) a common problem. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." ATI ATI D. "I keep forgetting which medications I have taken during the day." - Correct Ans-D. The nurse should identify that the greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications. A. The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority. B. The client is at risk for loss of independence and reduced self-esteem due to dependence upon their child. However, another issue is the priority. C. The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority. A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following should the nurse plan to include in the presentation? Select all that apply. A. Human papilloma virus (HPV) immunization B. Pneumococcal vaccination C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test - Correct Ans-B, C, D, E The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. A. The HPV vaccine is recommended for female clients from age 11 to 26 and male clients from age 9 to 26. It is not a recommendation for older adults. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? Select all that apply. A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite." - Correct Ans-C, D, E ATI ATI The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. A, B. The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake. A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? Select all that apply. A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation. - Correct Ans-A, C, D, E The nurse should identify that older adults should increase protein intake to increase muscle mass and improve wound healing, increase calcium intake to reduce the risk for osteoporosis, limit sodium intake to reduce the risk for edema and hypertension, and increase fiber intake to prevent constipation A nurse is teaching a client who has a new prescription for a time-release medication. What instructions should the nurse include? - Correct Ans-When taking actions, the nurse should instruct the client to swallow the time-release medication whole. These medications should not be crushed or chewed because time-released medications are intended to release slowly. Chewing or crushing the time-release medication causes all the medication to release at once, placing the client at risk for toxicity. A nurse is teaching a client how to self-administer ear drops. Which of the following client statements indicates an understanding of the teaching? A. "I will pull my ear down and back before I insert the drops." B. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C. "I will chill my ear drops before I use them." D. "I will place a cotton ball into my inner ear canal after the drops are in" - Correct Ans B. When evaluating outcomes, the nurse should identify that the client understands the instr