ATI RN Fundamental Nursing Test Bank – 170
Questions with Correct Answers and Rationales
1. A nurse is assessing a client who is receiving treatment for psoriasis.
Which of the following images depicts what the nurse should expect to
observe?
A. Well-defined, red, scaly patches with silvery plaques on the skin
B. Vesicles and crusting on an erythematous base
C. Linear burrows with intense itching
D. Thickened, lichenified plaques with excoriations
Correct Answer: A
Rationale:--Psoriasis presents as well-defined, red, scaly patches with
silvery plaques, often on elbows, knees, scalp.
2. A nurse is reinforcing discharge teaching with a client who has a new
colostomy. Which of the following instructions should the nurse
include?
A. Insert an enteric-coated aspirin into the ostomy bag to control odor.
B. Empty the ostomy bag when it becomes three-fourths full of stool.
C. Apply a skin barrier around the stoma when changing the ostomy bag.
D. Cleanse the stoma with moisturizing soap and water.
Correct Answer: B
Rationale:--Emptying when ¾ full prevents leakage and skin breakdown;
skin barrier is applied to peristomal skin, not around stoma; use mild soap,
not moisturizing, and no aspirin in bag.
3. A nurse is caring for a client who has a chest tube with a closed drainage
system. Which of the following actions should the nurse take?
A. Clamp the chest tube when ambulating the client.
B. Keep the drainage system below the level of the client's chest.
C. Strip the chest tube every 2 hours to maintain patency.
D. Empty the drainage system when it becomes full.
,Correct Answer: B
Rationale:--Keeping system below chest level promotes gravity drainage and
prevents backflow.
4. A nurse in a postpartum clinic is caring for a client who has returned for
her 6-week postpartum visit. The client states emphatically, "I hate when the
baby cries, and I can't get them to stop." Which of the following statements
should the nurse respond with?
A. "You should never hate your baby's crying."
B. "Many mothers feel this way at first; it will pass."
C. "Tell me more about what is going on when the baby starts crying."
D. "Have you considered asking your partner for help?"
Correct Answer: C
Rationale:--This open-ended response shows empathy and allows further
assessment of potential postpartum depression or coping difficulties.
5. A nurse is caring for a client who was administered more than the
prescribed dose of a medication. Which of the following actions should the
nurse take first?
A. Notify the provider.
B. Obtain the client's vital signs.
C. Administer the antidote.
D. Complete an incident report.
Correct Answer: B
Rationale:--First assess the client's physical status (vital signs) to identify signs of
toxicity or adverse effects.
6. A nurse is preparing to administer the 0900 medications. Which of the
following actions should the nurse take? (Select all that apply)
A. Apply sterile gloves.
B. Cut patch in half prior to applying.
C. Clean the IV injection port with an antiseptic swab.
D. Check for blood return of the IV catheter by gently pulling back on the
plunger of the syringe.
E. Check the client’s ID bracelet after administering the medication.
F. Clean area on skin with soap and water.
G. Flush IV catheter with 0.9% sodium chloride before and after
administering the medication.
,Correct Answers: C, D, G
Rationale:--Clean port with antiseptic; check blood return to confirm IV patency;
flush before and after to prevent incompatibility. ID bracelet checked before, not
after; patches not cut; sterile gloves not needed for routine IV push.
7. A nurse is reviewing the CDC's immunization recommendations with a
young adult client. Which of the following recommendations should the nurse
include? (Select all that apply)
A. Human papillomavirus (HPV)
B. Measles, mumps, rubella (MMR)
C. Varicella
D. Haemophilus influenzae type b (Hib)
E. Polio
Correct Answers: A, B, C
*Rationale:--Hib and polio are typically given in childhood; young adults may
need catch-up for MMR and varicella if not immune; HPV vaccine recommended
through age 26.*
8. A nurse is caring for an 82-year-old client in the ER who has an oral body
temp of 38.3°C (101°F), pulse 114/min, RR 22/min, restless, skin warm. Which
of the following are appropriate nursing interventions? (Select all that apply)
A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client's oral fluid intake.
C. Encourage the client to limit activity and rest.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.
Correct Answers: A, C, E
Rationale:--Cultures before antibiotics; rest reduces metabolic demand; oral
hygiene prevents cracked lips; shivering increases heat; fluids should be
encouraged, not restricted.
9. A nurse is instructing an AP in caring for a client who has a low platelet
count as a result of chemo. Which of the following is the nurse's priority
instruction for measuring vital signs for this client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
, Correct Answer: A
Rationale:--Low platelets increase bleeding risk; rectal thermometer insertion can
cause bleeding.
10. A nurse is instructing nursing students in measuring a client's respiratory
rate. Which of the following guidelines should the nurse include? (Select all
that apply)
A. Place the client in semi-Fowler's position.
B. Have the client rest an arm across the abdomen.
C. Observe 1 full respiratory cycle before counting the rate.
D. Count the rate for 1 min if it is regular.
E. Count and report any sighs the client demonstrates.
Correct Answers: A, B, C
Rationale:--Semi-Fowler's allows full chest expansion; arm across abdomen helps
observe movements; observe one cycle to identify pattern; count for full minute if
irregular; sighs are normal and not reported.
11. A nurse admitting a client with a fractured femur obtains a BP of 140/94
mm Hg. The client denies any history of hypertension. Which of the following
actions should the nurse take next?
A. Request a prescription for an antihypertensive med.
B. Ask the client if she is having pain.
C. Request a prescription for an anti-anxiety med.
D. Return in 30 min to recheck the client's BP.
Correct Answer: B
Rationale:--Pain from fracture can elevate BP; assess pain first before assuming
hypertension.
12. A nurse finds that a client's radial pulse is 68/min and simultaneous apical
pulse is 84/min. What is the client's pulse deficit?
Correct Answer: 16/min
*Rationale:--Pulse deficit = apical – radial = 84 – 68 = 16.*
13. A nurse is caring for a client who will perform fecal occult blood testing at
home. Which of the following information should the nurse include? (Select
all that apply)
A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color change indicates a positive test.
Questions with Correct Answers and Rationales
1. A nurse is assessing a client who is receiving treatment for psoriasis.
Which of the following images depicts what the nurse should expect to
observe?
A. Well-defined, red, scaly patches with silvery plaques on the skin
B. Vesicles and crusting on an erythematous base
C. Linear burrows with intense itching
D. Thickened, lichenified plaques with excoriations
Correct Answer: A
Rationale:--Psoriasis presents as well-defined, red, scaly patches with
silvery plaques, often on elbows, knees, scalp.
2. A nurse is reinforcing discharge teaching with a client who has a new
colostomy. Which of the following instructions should the nurse
include?
A. Insert an enteric-coated aspirin into the ostomy bag to control odor.
B. Empty the ostomy bag when it becomes three-fourths full of stool.
C. Apply a skin barrier around the stoma when changing the ostomy bag.
D. Cleanse the stoma with moisturizing soap and water.
Correct Answer: B
Rationale:--Emptying when ¾ full prevents leakage and skin breakdown;
skin barrier is applied to peristomal skin, not around stoma; use mild soap,
not moisturizing, and no aspirin in bag.
3. A nurse is caring for a client who has a chest tube with a closed drainage
system. Which of the following actions should the nurse take?
A. Clamp the chest tube when ambulating the client.
B. Keep the drainage system below the level of the client's chest.
C. Strip the chest tube every 2 hours to maintain patency.
D. Empty the drainage system when it becomes full.
,Correct Answer: B
Rationale:--Keeping system below chest level promotes gravity drainage and
prevents backflow.
4. A nurse in a postpartum clinic is caring for a client who has returned for
her 6-week postpartum visit. The client states emphatically, "I hate when the
baby cries, and I can't get them to stop." Which of the following statements
should the nurse respond with?
A. "You should never hate your baby's crying."
B. "Many mothers feel this way at first; it will pass."
C. "Tell me more about what is going on when the baby starts crying."
D. "Have you considered asking your partner for help?"
Correct Answer: C
Rationale:--This open-ended response shows empathy and allows further
assessment of potential postpartum depression or coping difficulties.
5. A nurse is caring for a client who was administered more than the
prescribed dose of a medication. Which of the following actions should the
nurse take first?
A. Notify the provider.
B. Obtain the client's vital signs.
C. Administer the antidote.
D. Complete an incident report.
Correct Answer: B
Rationale:--First assess the client's physical status (vital signs) to identify signs of
toxicity or adverse effects.
6. A nurse is preparing to administer the 0900 medications. Which of the
following actions should the nurse take? (Select all that apply)
A. Apply sterile gloves.
B. Cut patch in half prior to applying.
C. Clean the IV injection port with an antiseptic swab.
D. Check for blood return of the IV catheter by gently pulling back on the
plunger of the syringe.
E. Check the client’s ID bracelet after administering the medication.
F. Clean area on skin with soap and water.
G. Flush IV catheter with 0.9% sodium chloride before and after
administering the medication.
,Correct Answers: C, D, G
Rationale:--Clean port with antiseptic; check blood return to confirm IV patency;
flush before and after to prevent incompatibility. ID bracelet checked before, not
after; patches not cut; sterile gloves not needed for routine IV push.
7. A nurse is reviewing the CDC's immunization recommendations with a
young adult client. Which of the following recommendations should the nurse
include? (Select all that apply)
A. Human papillomavirus (HPV)
B. Measles, mumps, rubella (MMR)
C. Varicella
D. Haemophilus influenzae type b (Hib)
E. Polio
Correct Answers: A, B, C
*Rationale:--Hib and polio are typically given in childhood; young adults may
need catch-up for MMR and varicella if not immune; HPV vaccine recommended
through age 26.*
8. A nurse is caring for an 82-year-old client in the ER who has an oral body
temp of 38.3°C (101°F), pulse 114/min, RR 22/min, restless, skin warm. Which
of the following are appropriate nursing interventions? (Select all that apply)
A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client's oral fluid intake.
C. Encourage the client to limit activity and rest.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.
Correct Answers: A, C, E
Rationale:--Cultures before antibiotics; rest reduces metabolic demand; oral
hygiene prevents cracked lips; shivering increases heat; fluids should be
encouraged, not restricted.
9. A nurse is instructing an AP in caring for a client who has a low platelet
count as a result of chemo. Which of the following is the nurse's priority
instruction for measuring vital signs for this client?
A. "Don't measure the client's temp rectally."
B. "Count the client's radial pulse for 30 sec & multiply by 2."
C. "Don't let the client know you are counting her respirations."
D. "Let the client rest for 5 mins before you measure her BP."
, Correct Answer: A
Rationale:--Low platelets increase bleeding risk; rectal thermometer insertion can
cause bleeding.
10. A nurse is instructing nursing students in measuring a client's respiratory
rate. Which of the following guidelines should the nurse include? (Select all
that apply)
A. Place the client in semi-Fowler's position.
B. Have the client rest an arm across the abdomen.
C. Observe 1 full respiratory cycle before counting the rate.
D. Count the rate for 1 min if it is regular.
E. Count and report any sighs the client demonstrates.
Correct Answers: A, B, C
Rationale:--Semi-Fowler's allows full chest expansion; arm across abdomen helps
observe movements; observe one cycle to identify pattern; count for full minute if
irregular; sighs are normal and not reported.
11. A nurse admitting a client with a fractured femur obtains a BP of 140/94
mm Hg. The client denies any history of hypertension. Which of the following
actions should the nurse take next?
A. Request a prescription for an antihypertensive med.
B. Ask the client if she is having pain.
C. Request a prescription for an anti-anxiety med.
D. Return in 30 min to recheck the client's BP.
Correct Answer: B
Rationale:--Pain from fracture can elevate BP; assess pain first before assuming
hypertension.
12. A nurse finds that a client's radial pulse is 68/min and simultaneous apical
pulse is 84/min. What is the client's pulse deficit?
Correct Answer: 16/min
*Rationale:--Pulse deficit = apical – radial = 84 – 68 = 16.*
13. A nurse is caring for a client who will perform fecal occult blood testing at
home. Which of the following information should the nurse include? (Select
all that apply)
A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color change indicates a positive test.
