ATI Fundamental Concepts and Skills for
Nursing Complete Test Bank |
Questions and Answers with Rationales
| A+ Study Guide
Delegation of Tasks - ANSWER-A nurse should delegate providing postmortem care to
a client to assistive personnel.
Herbal Supplements Understanding - ANSWER-A client indicates understanding of
herbal supplements by stating they use ginger when they get car sick.
Infection Control - ANSWER-To prevent the spread of infection, a nurse should wear a
mask when working within 3 feet of a client with influenza.
Wrist Restraints Application - ANSWER-When applying wrist restraints, the nurse
should allow room for two fingers to fit between the client's skin and the restraints.
Transmission Precautions for Tuberculosis - ANSWER-A nurse should initiate airborne
transmission precautions for a client who has tuberculosis.
Response to Ingestion of Paint Thinner - ANSWER-If a child accidentally swallows paint
thinner and is awake and alert, the nurse should advise having the child drink one large
glass of water.
Documentation of Medical Records - ANSWER-A nurse should document 'Administered
pain medication' in a client's medical record.
Oral Care for Unconscious Client - ANSWER-For a client who is unconscious, the nurse
should place the client in a side-lying position for oral care.
Page 1 of 21
,Negligence in Nursing - ANSWER-An example of negligence is a nurse administering a
medication without first identifying the client.
Blood Transfusion Consent - ANSWER-A nurse begins a blood transfusion without
obtaining consent, which is an example of negligence.
Sputum Specimen Collection - ANSWER-When collecting a sputum specimen for
culture from a client with a respiratory infection, the nurse should wear sterile gloves.
Postmortem Care Delegation - ANSWER-Providing postmortem care is a task that can
be delegated to assistive personnel.
Herbal Use for Menopausal Symptoms - ANSWER-A client states they use garlic for
menopausal symptoms, indicating a use of herbal supplements.
Echinacea for Cholesterol Control - ANSWER-A client incorrectly states they take
echinacea to control cholesterol, showing a misunderstanding of herbal supplements.
Ginkgo Biloba for Headaches - ANSWER-A client states they take ginkgo biloba for
headaches, indicating a use of herbal supplements.
Protective Eyewear Use - ANSWER-A nurse should don protective eyewear before
entering the room of a client with infection precautions.
Negative Airflow Room - ANSWER-A nurse should place a client with tuberculosis in a
negative airflow room.
Inducing Vomiting - ANSWER-Inducing vomiting in a child who swallowed paint thinner
is not recommended; the nurse should advise against it.
Fluid Intake Documentation - ANSWER-Documenting 'Drank adequate amounts of fluid
with meals' is not specific enough for a medical record.
Page 2 of 21
, Temperature Documentation - ANSWER-Documenting 'Oral temperature slightly
elevated at 0800' is an appropriate entry for a medical record.
Assistive Personnel Confidentiality - ANSWER-An assistive personnel discussing client
care in a cafeteria with visitors present is a breach of confidentiality.
Pain Medication Administration - ANSWER-Documenting 'Administered pain
medication' is a clear and concise entry for a medical record.
Client's Response to Diuretic - ANSWER-Determining a client's response to a diuretic is
a task that should not be delegated to assistive personnel.
Sterile gloves - ANSWER-Wear sterile gloves when collecting the specimen.
Oral hygiene after specimen collection - ANSWER-Offer the client oral hygiene after the
collection.
Specimen collection timing - ANSWER-Collect the specimen in the evening.
Sputum collection volume - ANSWER-Collect 1 ml of sputum.
Older client assessment findings - ANSWER-A nurse is assessing an older client.
Expected finding: decreased sense of balance.
Nighttime urinary incontinence - ANSWER-Nighttime urinary incontinence is an
expected finding in older clients.
Ostomy pouch opening size - ANSWER-Cut the opening of the pouch 1⁄8 of an inch
larger than the stoma.
Gauze over stoma - ANSWER-Place a piece of gauze over the stoma while changing
the pouch.
Cleaning around stoma - ANSWER-Use povidone-iodine to clean around the stoma.
Page 3 of 21
Nursing Complete Test Bank |
Questions and Answers with Rationales
| A+ Study Guide
Delegation of Tasks - ANSWER-A nurse should delegate providing postmortem care to
a client to assistive personnel.
Herbal Supplements Understanding - ANSWER-A client indicates understanding of
herbal supplements by stating they use ginger when they get car sick.
Infection Control - ANSWER-To prevent the spread of infection, a nurse should wear a
mask when working within 3 feet of a client with influenza.
Wrist Restraints Application - ANSWER-When applying wrist restraints, the nurse
should allow room for two fingers to fit between the client's skin and the restraints.
Transmission Precautions for Tuberculosis - ANSWER-A nurse should initiate airborne
transmission precautions for a client who has tuberculosis.
Response to Ingestion of Paint Thinner - ANSWER-If a child accidentally swallows paint
thinner and is awake and alert, the nurse should advise having the child drink one large
glass of water.
Documentation of Medical Records - ANSWER-A nurse should document 'Administered
pain medication' in a client's medical record.
Oral Care for Unconscious Client - ANSWER-For a client who is unconscious, the nurse
should place the client in a side-lying position for oral care.
Page 1 of 21
,Negligence in Nursing - ANSWER-An example of negligence is a nurse administering a
medication without first identifying the client.
Blood Transfusion Consent - ANSWER-A nurse begins a blood transfusion without
obtaining consent, which is an example of negligence.
Sputum Specimen Collection - ANSWER-When collecting a sputum specimen for
culture from a client with a respiratory infection, the nurse should wear sterile gloves.
Postmortem Care Delegation - ANSWER-Providing postmortem care is a task that can
be delegated to assistive personnel.
Herbal Use for Menopausal Symptoms - ANSWER-A client states they use garlic for
menopausal symptoms, indicating a use of herbal supplements.
Echinacea for Cholesterol Control - ANSWER-A client incorrectly states they take
echinacea to control cholesterol, showing a misunderstanding of herbal supplements.
Ginkgo Biloba for Headaches - ANSWER-A client states they take ginkgo biloba for
headaches, indicating a use of herbal supplements.
Protective Eyewear Use - ANSWER-A nurse should don protective eyewear before
entering the room of a client with infection precautions.
Negative Airflow Room - ANSWER-A nurse should place a client with tuberculosis in a
negative airflow room.
Inducing Vomiting - ANSWER-Inducing vomiting in a child who swallowed paint thinner
is not recommended; the nurse should advise against it.
Fluid Intake Documentation - ANSWER-Documenting 'Drank adequate amounts of fluid
with meals' is not specific enough for a medical record.
Page 2 of 21
, Temperature Documentation - ANSWER-Documenting 'Oral temperature slightly
elevated at 0800' is an appropriate entry for a medical record.
Assistive Personnel Confidentiality - ANSWER-An assistive personnel discussing client
care in a cafeteria with visitors present is a breach of confidentiality.
Pain Medication Administration - ANSWER-Documenting 'Administered pain
medication' is a clear and concise entry for a medical record.
Client's Response to Diuretic - ANSWER-Determining a client's response to a diuretic is
a task that should not be delegated to assistive personnel.
Sterile gloves - ANSWER-Wear sterile gloves when collecting the specimen.
Oral hygiene after specimen collection - ANSWER-Offer the client oral hygiene after the
collection.
Specimen collection timing - ANSWER-Collect the specimen in the evening.
Sputum collection volume - ANSWER-Collect 1 ml of sputum.
Older client assessment findings - ANSWER-A nurse is assessing an older client.
Expected finding: decreased sense of balance.
Nighttime urinary incontinence - ANSWER-Nighttime urinary incontinence is an
expected finding in older clients.
Ostomy pouch opening size - ANSWER-Cut the opening of the pouch 1⁄8 of an inch
larger than the stoma.
Gauze over stoma - ANSWER-Place a piece of gauze over the stoma while changing
the pouch.
Cleaning around stoma - ANSWER-Use povidone-iodine to clean around the stoma.
Page 3 of 21
