ATI fundamentals practice A
A nurse is evaluating a client's use of a cane. Which of the following actions should the
nurse identify as an indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.
3
The client should hold the cane on the stronger side of her body to increase support and
maintain alignment.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at
125mL/hr. When the nurse performs the initial assessment, he notes that the client has
received only 80mL over the last 2 hr. Which of the following actions should the nurse
take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction.
4
The first action the nurse should take using the nursing process is to assess the client. If
checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate
the flow of fluid through the tubing. This could re-establish the infusion rate the provider
prescribed.
A nurse is caring for a client who requires an NG tube for stomach decompression.
Which of the following actions should the nurse take when inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG
tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube into the
esophagus.
4
Taking sips of water as the NG tube passes through the oropharynx will close the
epiglottis over the trachea and prevent the tube from passing into the trachea.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings
should the nurse report to the provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L
4
This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse
should report this finding to the provider. This client is at risk for dysrhythmias.
, A nurse is providing discharge instructions to a client who will be using a walker. Which
of the following client statements indicates an understanding of the teaching?
1."I can place an extension cord across my living room to plug in my television."
2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one."
2
Clearing stairs of any object that could cause the client to trip or require them to bend
over while walking will decrease the risk for falls.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and
dysphagia. Which of the following tasks should the nurse assign to an assistive
personnel? SATA
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an antihypertensive medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter.
1, 2, 4
Assisting a client with a bed bath poses minimal risk to the client and is within the AP's
range of function.
Measuring a client's BP poses minimal risk to the client and is within the AP's range of
function.
Using a communication board poses minimal risk to the client and is within the AP's
range of function.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take?
1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to manage his illness.
3. Provide the client with written information about the phases of loss and grief.
4. Reassure the client that this is an expected response to grief.
4
During the anger stage of the client's psychosocial adaptation to illness, the nurse
should support the client and explain that this is an expected reaction to a cancer
diagnosis.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressings should the nurse use?
1. Alginate
2. Gauze
3. Transparent
4. Hydrocolloid
4
Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist
wound bed.
A nurse is administering an otic medication to an older adult client. Which of the
following actions should the nurse take to ensure the medication reaches the inner ear?
1. Press gently on the tragus of the client's ear.
A nurse is evaluating a client's use of a cane. Which of the following actions should the
nurse identify as an indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.
3
The client should hold the cane on the stronger side of her body to increase support and
maintain alignment.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at
125mL/hr. When the nurse performs the initial assessment, he notes that the client has
received only 80mL over the last 2 hr. Which of the following actions should the nurse
take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction.
4
The first action the nurse should take using the nursing process is to assess the client. If
checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate
the flow of fluid through the tubing. This could re-establish the infusion rate the provider
prescribed.
A nurse is caring for a client who requires an NG tube for stomach decompression.
Which of the following actions should the nurse take when inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG
tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube into the
esophagus.
4
Taking sips of water as the NG tube passes through the oropharynx will close the
epiglottis over the trachea and prevent the tube from passing into the trachea.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings
should the nurse report to the provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L
4
This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse
should report this finding to the provider. This client is at risk for dysrhythmias.
, A nurse is providing discharge instructions to a client who will be using a walker. Which
of the following client statements indicates an understanding of the teaching?
1."I can place an extension cord across my living room to plug in my television."
2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one."
2
Clearing stairs of any object that could cause the client to trip or require them to bend
over while walking will decrease the risk for falls.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and
dysphagia. Which of the following tasks should the nurse assign to an assistive
personnel? SATA
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an antihypertensive medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter.
1, 2, 4
Assisting a client with a bed bath poses minimal risk to the client and is within the AP's
range of function.
Measuring a client's BP poses minimal risk to the client and is within the AP's range of
function.
Using a communication board poses minimal risk to the client and is within the AP's
range of function.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take?
1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to manage his illness.
3. Provide the client with written information about the phases of loss and grief.
4. Reassure the client that this is an expected response to grief.
4
During the anger stage of the client's psychosocial adaptation to illness, the nurse
should support the client and explain that this is an expected reaction to a cancer
diagnosis.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressings should the nurse use?
1. Alginate
2. Gauze
3. Transparent
4. Hydrocolloid
4
Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist
wound bed.
A nurse is administering an otic medication to an older adult client. Which of the
following actions should the nurse take to ensure the medication reaches the inner ear?
1. Press gently on the tragus of the client's ear.
