ATI RN CONCEPT BASED ASSESSMENT LEVEL 1 PROCTORED
COMPLETE EXAM LATEST VERIFIED QUESTIONS % DETAILED
ANSWERS
A nurse is planning care who has an indwelling urinary
catheter. Which of the following interventions include in the
plan to prevent the development of a catheter-associated
urinary tract infection (cauti)?
Secure the catheter tubing to the client's leg.
(the nurse should assess the client's need for urinary
catheterization and should follow evidence-based practice to
prevent or reduce the risk of cauti development. This includes
securing the catheter tubing to the client's leg so that the
catheter does not move, reducing the risk of urethral trauma
and introduction of bacteria into the urinary system.)
A nurse is caring for a 2-year-old toddler who is immediately
postoperative. Which of the following pain scales should the
nurse use to access the toddler's pain level?
Flacc scale
(the nurse should use the flacc scale to assess pain for a 2-
year-old child. The flacc scale assesses facial expression, leg
movement, activity, cry, and consolability in children 2 months
to 7 years of age. The nurse assigns a score of 0 to 2 for each
area.)
Page 1 of 43
,A nurse is caring for a client who has cancer and is planning
discharge to home with hospice care. Which of the following
statements by the client indicates that he is experiencing
spiritual distress?
"i wish god had not allowed this cancer to invade my body."
(the nurse should identify that this statement indicates the
client is experiencing spiritual distress, which occurs when
there is a disturbance in a client's belief system. This client is
expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer
and is scheduled for chemotherapy. The client reports
experiencing chemotherapy-induced nausea and vomiting
(cinv) during her previous round of treatment. Which of the
following interventions should the nurse include in the client's
plan of care?
Administer ondansetron to the client prior to chemotherapy
administration.
(the nurse should incorporate evidence-based practice
interventions into the client's plan of care to prevent and treat
cinv. Evidence-based research indicates that prevention of
cinv is best achieved when antiemetics, such as ondansetron,
are given prior to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client
following a brief stay in acute care. In adherence with the joint
commission national patient safety goals regarding medication
Page 2 of 43
,administration, which of the following actions should the nurse
take?
Compare a list of the client's current medications with the
ones he will take in long-term care.
(the joint commission national patient safety goals regarding
medication reconciliation includes maintaining and
communicating accurate client medication information. The
nurse should complete a medication reconciliation to identify
and resolve any discrepancies by comparing the client's list of
current medications with the medications he will take in the
long-term care facility and addressing any duplications,
omissions, or interactions.)
A nurse in a long-term care facility is performing a fall risk
assessment on a newly admitted client using the timed up and
go (tug) test. The client reports using a tripod cane for
ambulation. Which of the following actions should the nurse
take when using this test?
Observe the client ambulating a distance of 3 m (10 feet)
during the tug test.
(the nurse should mark a spot 3 m (10 feet) away from the
client's sitting location. The nurse should instruct the client to
stand, ambulate to the marked spot, turn, ambulate back to the
chair, and sit down. The nurse should observe the client's
ability to perform the test and use a stopwatch to time the
client. The nurse should identify that the client is at increased
risk of falls if it takes longer than 14 seconds to complete the
test.)
Page 3 of 43
, A nurse in an orthopedic clinic is documenting data about
several clients. Which of the following actions should the
nurse take to comply with the regulations of the health
portability and accountability act (hipaa)?
Lock or log off computers whenever he leaves the area.
(to prevent unauthorized access to clients' protected health
information, all clinic staff should lock or log off computer
terminals and turn off the monitor anytime they leave the
computer unattended. This action demonstrates compliance
with the hipaa security rule.)
A home health nurse is providing teaching to the parent of a
child who is receiving chemotherapy and experiencing nausea.
Which of the following statements should the nurse make?
"have your child rest with his head elevated after meals."
(the nurse should instruct the parent to have the child rest
with his head elevated after meals. This will allow for easier
digestion and help to decrease the nausea associated with
eating.)
A nurse is preparing to document care in a client's medical
record. In adherence with the joint commission national
patient safety goals regarding communication errors, which of
the following entries should the nurse make?
"client medicated with morphine 5 mg im for pain."
Page 4 of 43
COMPLETE EXAM LATEST VERIFIED QUESTIONS % DETAILED
ANSWERS
A nurse is planning care who has an indwelling urinary
catheter. Which of the following interventions include in the
plan to prevent the development of a catheter-associated
urinary tract infection (cauti)?
Secure the catheter tubing to the client's leg.
(the nurse should assess the client's need for urinary
catheterization and should follow evidence-based practice to
prevent or reduce the risk of cauti development. This includes
securing the catheter tubing to the client's leg so that the
catheter does not move, reducing the risk of urethral trauma
and introduction of bacteria into the urinary system.)
A nurse is caring for a 2-year-old toddler who is immediately
postoperative. Which of the following pain scales should the
nurse use to access the toddler's pain level?
Flacc scale
(the nurse should use the flacc scale to assess pain for a 2-
year-old child. The flacc scale assesses facial expression, leg
movement, activity, cry, and consolability in children 2 months
to 7 years of age. The nurse assigns a score of 0 to 2 for each
area.)
Page 1 of 43
,A nurse is caring for a client who has cancer and is planning
discharge to home with hospice care. Which of the following
statements by the client indicates that he is experiencing
spiritual distress?
"i wish god had not allowed this cancer to invade my body."
(the nurse should identify that this statement indicates the
client is experiencing spiritual distress, which occurs when
there is a disturbance in a client's belief system. This client is
expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer
and is scheduled for chemotherapy. The client reports
experiencing chemotherapy-induced nausea and vomiting
(cinv) during her previous round of treatment. Which of the
following interventions should the nurse include in the client's
plan of care?
Administer ondansetron to the client prior to chemotherapy
administration.
(the nurse should incorporate evidence-based practice
interventions into the client's plan of care to prevent and treat
cinv. Evidence-based research indicates that prevention of
cinv is best achieved when antiemetics, such as ondansetron,
are given prior to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client
following a brief stay in acute care. In adherence with the joint
commission national patient safety goals regarding medication
Page 2 of 43
,administration, which of the following actions should the nurse
take?
Compare a list of the client's current medications with the
ones he will take in long-term care.
(the joint commission national patient safety goals regarding
medication reconciliation includes maintaining and
communicating accurate client medication information. The
nurse should complete a medication reconciliation to identify
and resolve any discrepancies by comparing the client's list of
current medications with the medications he will take in the
long-term care facility and addressing any duplications,
omissions, or interactions.)
A nurse in a long-term care facility is performing a fall risk
assessment on a newly admitted client using the timed up and
go (tug) test. The client reports using a tripod cane for
ambulation. Which of the following actions should the nurse
take when using this test?
Observe the client ambulating a distance of 3 m (10 feet)
during the tug test.
(the nurse should mark a spot 3 m (10 feet) away from the
client's sitting location. The nurse should instruct the client to
stand, ambulate to the marked spot, turn, ambulate back to the
chair, and sit down. The nurse should observe the client's
ability to perform the test and use a stopwatch to time the
client. The nurse should identify that the client is at increased
risk of falls if it takes longer than 14 seconds to complete the
test.)
Page 3 of 43
, A nurse in an orthopedic clinic is documenting data about
several clients. Which of the following actions should the
nurse take to comply with the regulations of the health
portability and accountability act (hipaa)?
Lock or log off computers whenever he leaves the area.
(to prevent unauthorized access to clients' protected health
information, all clinic staff should lock or log off computer
terminals and turn off the monitor anytime they leave the
computer unattended. This action demonstrates compliance
with the hipaa security rule.)
A home health nurse is providing teaching to the parent of a
child who is receiving chemotherapy and experiencing nausea.
Which of the following statements should the nurse make?
"have your child rest with his head elevated after meals."
(the nurse should instruct the parent to have the child rest
with his head elevated after meals. This will allow for easier
digestion and help to decrease the nausea associated with
eating.)
A nurse is preparing to document care in a client's medical
record. In adherence with the joint commission national
patient safety goals regarding communication errors, which of
the following entries should the nurse make?
"client medicated with morphine 5 mg im for pain."
Page 4 of 43
