A.T.I PN FUNDAMENTALS
,7. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
findings should the nurse identify as a safety hazard?
a) An assistive personnel places a weight-sensitive sensor mat on the mattress beneath
the client’s buttocks.
b) An assistive personnel raises all four side rails of a client’s bed before leaving the
room.
c) A client who has bilateral wrist restraints has a capillary refill less than 2 seconds.
d) A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing
sensation at the application site.
8. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation. Which of the following statements by the client should the nurse identify as
indicating an acceptance of the limb loss?
a) “I stay awake at night because I keep thinking about my leg.”
b) “I need to learn how to perform a dressing change on my leg.”
c) “I know my family means well, but I don’t want visitors seeing my leg right now.”
d) “I am going to have to find someone who can take care of my leg at home.”
9. A nurse on a medical-surgical unit is collecting data from a client who is postoperative
following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse
now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should
the nurse make?
a) Measure the client’s BP in the other arm.
b) Use a narrower cuff to repeat the BP measurement.
c) Deflate the cuff faster when repeating the bp measurement.
d) Request a prescription for an antihypertension medication.
10. A nurse is assisting with the admission of a client who has streptococcal pharyngitis.
Which of the following precautions should the nurse make?
a) Have the client’s visitors put on a gown before entering the room.
b) Escort the client to a room with a negative airglow.
c) Prohibit fresh flowers and plants in the client’s room.
d) Wear a surgical mask when giving the client direct care.
,11. A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which
of the following images indicates the type of face mask the nurse should use to deliver
the client a 90% oxygen concentration?
12. A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has
difficulty swallowing during meals. Which of the following actions should the nurse take
to prevent the client from aspiration while eating?
a) Add liquid to foods to thin consistency.
b) Tilt the clients head slightly backward.
c) Offer verbal support while the client is eating.
d) Encourage socialization with others during meals.
13. A nurse in a provider’s office performs a fecal occult blood test with a positive result on a
client. Which of the following clients may have a false positive result?
a) A client who has a venous stasis ulcer.
b) A client who takes an iron supplement.
c) A client who has peripheral hematomas.
d) A client who underwent a barium swallow study.
14. A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F).
Which of the following actions should the nurse take?
a) Give the client an alcohol sponge bath.
b) Place cold packs on the client’s axillae.
c) Place a fan to blow air across the client.
d) Remove blankets from the client.
15. A nurse is caring for a client who has a hip fracture and plans to administer a pain
medication prior to turning the client. Which of the following ethical principles is the
nurse implementing?
a) Beneficence.
b) Fidelity.
c) Autonomy.
, d) Veracity.
16. A nurse is caring for a client who was recently admitted to hospice care and tells the
nurse “I am going to die, and my family is hoping for a cure. I am mad that they behave
like everything will be fine.” Which of the following responses should the nurse make?
a) “It sounds like you have given up and you want to stay mad at your family.”
b) “Why do you think they don’t know what’s happening?”
c) “You are feeling angry that your family continues to wish for a cure?”
d) “I think you and I need to talk about your anger with your family.”
17. A nurse in a provider’s office is reviewing the medical record of an older adult who
report’s having nausea and vomiting for the last 48 hrs. Which of the following findings
indicate fluid volume deficit? (Select all that apply.)
a) Dry mucous membranes.
b) Decreased skin turgor.
c) Heart rate 72/min.
d) Distended neck veins.
e) Blood pressure 88/62 mm Hg.
18. A nurse is caring for a client who refuses a prescribed medical procedure. Which of the
following actions should the nurse take to act as the client’s advocate?
a) Evaluate the client’s concerns and communicate them to the provider.
b) Ask the client’s partner to find out why the client has refused the procedure.
c) Explain the necessity of the procedure to the client.
d) Contact the unit’s social worker to report the client’s refusal.
19. A nurse is assisting with scoliosis screenings for students at a public school. Which of the
following findings should the nurse recognize as an indication of scoliosis?
a) Expansion of the upper intercostal spaces.
b) Increased convex curve of the cervical spine.
c) Increased concave curve of the thoracic spine.
d) Unequal height of the shoulders.
20. A nurse is disinfecting the room of a client who has a Clostridium difficile infection.
Which of the following solutions should the nurse use?
a) Isopropyl alcohol.
b) Triclosan.
c) Chlorhexidine.
d) Chlorine bleach.
21. A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per
day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/
10 mL. How many mL should the nurse administer per dose? (Round to the nearest
whole number.) mL (80x35÷1*1000 x10) /4 =7 mL
,7. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
findings should the nurse identify as a safety hazard?
a) An assistive personnel places a weight-sensitive sensor mat on the mattress beneath
the client’s buttocks.
b) An assistive personnel raises all four side rails of a client’s bed before leaving the
room.
c) A client who has bilateral wrist restraints has a capillary refill less than 2 seconds.
d) A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing
sensation at the application site.
8. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation. Which of the following statements by the client should the nurse identify as
indicating an acceptance of the limb loss?
a) “I stay awake at night because I keep thinking about my leg.”
b) “I need to learn how to perform a dressing change on my leg.”
c) “I know my family means well, but I don’t want visitors seeing my leg right now.”
d) “I am going to have to find someone who can take care of my leg at home.”
9. A nurse on a medical-surgical unit is collecting data from a client who is postoperative
following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse
now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should
the nurse make?
a) Measure the client’s BP in the other arm.
b) Use a narrower cuff to repeat the BP measurement.
c) Deflate the cuff faster when repeating the bp measurement.
d) Request a prescription for an antihypertension medication.
10. A nurse is assisting with the admission of a client who has streptococcal pharyngitis.
Which of the following precautions should the nurse make?
a) Have the client’s visitors put on a gown before entering the room.
b) Escort the client to a room with a negative airglow.
c) Prohibit fresh flowers and plants in the client’s room.
d) Wear a surgical mask when giving the client direct care.
,11. A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which
of the following images indicates the type of face mask the nurse should use to deliver
the client a 90% oxygen concentration?
12. A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has
difficulty swallowing during meals. Which of the following actions should the nurse take
to prevent the client from aspiration while eating?
a) Add liquid to foods to thin consistency.
b) Tilt the clients head slightly backward.
c) Offer verbal support while the client is eating.
d) Encourage socialization with others during meals.
13. A nurse in a provider’s office performs a fecal occult blood test with a positive result on a
client. Which of the following clients may have a false positive result?
a) A client who has a venous stasis ulcer.
b) A client who takes an iron supplement.
c) A client who has peripheral hematomas.
d) A client who underwent a barium swallow study.
14. A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F).
Which of the following actions should the nurse take?
a) Give the client an alcohol sponge bath.
b) Place cold packs on the client’s axillae.
c) Place a fan to blow air across the client.
d) Remove blankets from the client.
15. A nurse is caring for a client who has a hip fracture and plans to administer a pain
medication prior to turning the client. Which of the following ethical principles is the
nurse implementing?
a) Beneficence.
b) Fidelity.
c) Autonomy.
, d) Veracity.
16. A nurse is caring for a client who was recently admitted to hospice care and tells the
nurse “I am going to die, and my family is hoping for a cure. I am mad that they behave
like everything will be fine.” Which of the following responses should the nurse make?
a) “It sounds like you have given up and you want to stay mad at your family.”
b) “Why do you think they don’t know what’s happening?”
c) “You are feeling angry that your family continues to wish for a cure?”
d) “I think you and I need to talk about your anger with your family.”
17. A nurse in a provider’s office is reviewing the medical record of an older adult who
report’s having nausea and vomiting for the last 48 hrs. Which of the following findings
indicate fluid volume deficit? (Select all that apply.)
a) Dry mucous membranes.
b) Decreased skin turgor.
c) Heart rate 72/min.
d) Distended neck veins.
e) Blood pressure 88/62 mm Hg.
18. A nurse is caring for a client who refuses a prescribed medical procedure. Which of the
following actions should the nurse take to act as the client’s advocate?
a) Evaluate the client’s concerns and communicate them to the provider.
b) Ask the client’s partner to find out why the client has refused the procedure.
c) Explain the necessity of the procedure to the client.
d) Contact the unit’s social worker to report the client’s refusal.
19. A nurse is assisting with scoliosis screenings for students at a public school. Which of the
following findings should the nurse recognize as an indication of scoliosis?
a) Expansion of the upper intercostal spaces.
b) Increased convex curve of the cervical spine.
c) Increased concave curve of the thoracic spine.
d) Unequal height of the shoulders.
20. A nurse is disinfecting the room of a client who has a Clostridium difficile infection.
Which of the following solutions should the nurse use?
a) Isopropyl alcohol.
b) Triclosan.
c) Chlorhexidine.
d) Chlorine bleach.
21. A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per
day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/
10 mL. How many mL should the nurse administer per dose? (Round to the nearest
whole number.) mL (80x35÷1*1000 x10) /4 =7 mL
