ATI FUNDAMENTAL PRACTICE
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – should be free of
feces
b. I have a specimen in the bathroom from about 30 minutes ago- Client should
place any urine in the container immediately and keep it on ice or in the fridge.
c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr
urine collection, the client should discard the first voiding and save all
subsequent voiding.
d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified
amount
2. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has
developed thrombophlebitis?
a. Bladder distention – urinary retention which causes bladder distension is a
common complication of bed rest due to a loss of muscle tone in the bladder
and detrusor muscles
b. Decreased blood pressure – client on bed rest can develop postural hypotension.
Drop in BP when the client moves from a lying to a sitting position. Nurse should
assess for pulse rate and dizziness.
c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of
thrombophlebitis, a common complication of immobility
d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis.
Constipation is common complication of immobility.
3. A nurse manager is overseeing the care on a unit. Which of the following situations
should the nurse manager identify as a violation of HIPAA guidelines?
a. A nurse who is caring for a client reviews the client's medical chart with the
nursing student who is working with the nurse – any healthcare professional
directly caring for a client has access to the medical information.
b. A nurse asks a nurse from another unit to assist with her documentation – only
health care professionals directly caring for a client may access medical
information.
c. A nurse who is caring for a client returns a call to the client's durable power of
attorney for healthcare designee to discuss the client's care – The person the
, durable power of attorney for health care designates has a legal right to
information about the client’s care.
d. A nurse discusses the client's status with the physical therapist that is caring for
the client at the client's bedside – any healthcare professional directly caring for
a client has access to the medical information.
4. A nurse is caring for a client who requires bed rest and has a prescription for
antiembolic stockings. Which of the following actions should the nurse take?
a. Apply the stockings so the creases are on the front side of the leg – nurse should
assure that there are no creases or wrinkles in the stocked to prevent kind
irritation and promote venous return
b. Apply the stockings while the client's legs are in a dependent position – nurse
should apply stockings in the morning before the client gets our o bed because
the legs are less edematous at that time
c. Remove the stockings at least once per shif – nurse should remove stocking to
check for CMS.
d. Remove the stockings while the client is sitting in a reclining chair – Client should
wear the stockings while sitting in the chair to promote venous return.
5. A nurse is administering IV fluid to an older adult client. The nurse should perform
which priority assessment to monitor for adverse effects?
a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor for
fluid volume excess, a complication of IV therapy. Manifested in moist crackles
heard in lung fields, dyspnea, and SOB
b. Measure urine output – The nurse should measure urine output to monitor the
renal function of an older client, however it is not the priority assessment
c. Monitor blood pressure readings - The nurse should monitor BP readings to
evaluate the hemodynamic stability of an older client, however it is not the
priority assessment
d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte
levels (esp Na) to guide the planning of interventions to correct any imbalances
in an older client, however it is not the priority assessment
6. A nurse is assessing a client's readiness to learn about insulin administration. Which of
the following statements should the nurse identify as an indication that the client is
ready to learn?
a. I can concentrate best in the morning – best indicates readiness to learn bc he is
verbalizing the best time frame for him to learn
b. It is difficult to read the instructions because my glasses are at home
c. I'm wondering why I need to learn this
d. You will have to talk to my wife about this
7. A nurse is performing a Romberg's test during the physical assessment of a client. Which
of the following techniques should the nurse use?
a. Touch the face with a cotton ball – tests CN 5 - trigeminal
, b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound
lateralization for hearing
c. Have the client stand with her arms at her side and her feet together –
Romberg’s test helps identify alterations in balance. The nurse should observe
for swaying and loss of balance
d. Perform direct percussion over the area of the kidneys – This evaluates for
kidney inflammation
8. A nurse is planning an education session for an older adult client who has just learned
that she has type 2 diabetes mellitus. Which of the following strategies should the nurse
plan to use with this client?
a. Allow extra time for the client to respond to questions – Older clients process
information at a slower rate than younger clients. The nurse should plan for
extra time to allow for questions and absorption of information
b. Expect the client to have difficulty understanding the information – cognitive
abilities vary between individuals. Rather than expecting misunderstanding, the
nurse should assess their cognition and ability to learn, teach, and understand.
c. Avoid references to the client's past experiences – The nurse should explore
their past experience and use them to establish connections to new knowledge
d. Keep the learning session private and one-on-one – It is helpful when working
with older adult clients to invite another household member to the teaching
session so that person can help reinforce new information later. The nurse
should also honor the client’s preference for one-on-one or group settings.
9. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the
nurse recommend?
a. Walking briskly – weight bearing exercises are essential for maintaining bone
mass, which helps to prevent osteoporosis. Walking engages older adults in this
preventative and therapeutic strategies
b. Riding a bicycle
c. Performing isometric exercises
d. Engaging in high-impact aerobics
10. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The
nurse should identify that which of the following findings requires further intervention.
a. Erythema on pressure points – requires prompt relief of pressure and additional
measures to protect the skin from further breakdown
b. Lower extremity pulse strength of 2+ - expected finding
c. Fluid intake of 3000 mL per day – clients should drink 2.5-3L a day
d. A bowel movement every other day – bowel movements less frequent than
3x/week indicate constipation and need for intervention
11. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a
client. Which of the following actions should the nurse take?
QUESTIONS AND ANSWERS
1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – should be free of
feces
b. I have a specimen in the bathroom from about 30 minutes ago- Client should
place any urine in the container immediately and keep it on ice or in the fridge.
c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24 hr
urine collection, the client should discard the first voiding and save all
subsequent voiding.
d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified
amount
2. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has
developed thrombophlebitis?
a. Bladder distention – urinary retention which causes bladder distension is a
common complication of bed rest due to a loss of muscle tone in the bladder
and detrusor muscles
b. Decreased blood pressure – client on bed rest can develop postural hypotension.
Drop in BP when the client moves from a lying to a sitting position. Nurse should
assess for pulse rate and dizziness.
c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations of
thrombophlebitis, a common complication of immobility
d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis.
Constipation is common complication of immobility.
3. A nurse manager is overseeing the care on a unit. Which of the following situations
should the nurse manager identify as a violation of HIPAA guidelines?
a. A nurse who is caring for a client reviews the client's medical chart with the
nursing student who is working with the nurse – any healthcare professional
directly caring for a client has access to the medical information.
b. A nurse asks a nurse from another unit to assist with her documentation – only
health care professionals directly caring for a client may access medical
information.
c. A nurse who is caring for a client returns a call to the client's durable power of
attorney for healthcare designee to discuss the client's care – The person the
, durable power of attorney for health care designates has a legal right to
information about the client’s care.
d. A nurse discusses the client's status with the physical therapist that is caring for
the client at the client's bedside – any healthcare professional directly caring for
a client has access to the medical information.
4. A nurse is caring for a client who requires bed rest and has a prescription for
antiembolic stockings. Which of the following actions should the nurse take?
a. Apply the stockings so the creases are on the front side of the leg – nurse should
assure that there are no creases or wrinkles in the stocked to prevent kind
irritation and promote venous return
b. Apply the stockings while the client's legs are in a dependent position – nurse
should apply stockings in the morning before the client gets our o bed because
the legs are less edematous at that time
c. Remove the stockings at least once per shif – nurse should remove stocking to
check for CMS.
d. Remove the stockings while the client is sitting in a reclining chair – Client should
wear the stockings while sitting in the chair to promote venous return.
5. A nurse is administering IV fluid to an older adult client. The nurse should perform
which priority assessment to monitor for adverse effects?
a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor for
fluid volume excess, a complication of IV therapy. Manifested in moist crackles
heard in lung fields, dyspnea, and SOB
b. Measure urine output – The nurse should measure urine output to monitor the
renal function of an older client, however it is not the priority assessment
c. Monitor blood pressure readings - The nurse should monitor BP readings to
evaluate the hemodynamic stability of an older client, however it is not the
priority assessment
d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte
levels (esp Na) to guide the planning of interventions to correct any imbalances
in an older client, however it is not the priority assessment
6. A nurse is assessing a client's readiness to learn about insulin administration. Which of
the following statements should the nurse identify as an indication that the client is
ready to learn?
a. I can concentrate best in the morning – best indicates readiness to learn bc he is
verbalizing the best time frame for him to learn
b. It is difficult to read the instructions because my glasses are at home
c. I'm wondering why I need to learn this
d. You will have to talk to my wife about this
7. A nurse is performing a Romberg's test during the physical assessment of a client. Which
of the following techniques should the nurse use?
a. Touch the face with a cotton ball – tests CN 5 - trigeminal
, b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound
lateralization for hearing
c. Have the client stand with her arms at her side and her feet together –
Romberg’s test helps identify alterations in balance. The nurse should observe
for swaying and loss of balance
d. Perform direct percussion over the area of the kidneys – This evaluates for
kidney inflammation
8. A nurse is planning an education session for an older adult client who has just learned
that she has type 2 diabetes mellitus. Which of the following strategies should the nurse
plan to use with this client?
a. Allow extra time for the client to respond to questions – Older clients process
information at a slower rate than younger clients. The nurse should plan for
extra time to allow for questions and absorption of information
b. Expect the client to have difficulty understanding the information – cognitive
abilities vary between individuals. Rather than expecting misunderstanding, the
nurse should assess their cognition and ability to learn, teach, and understand.
c. Avoid references to the client's past experiences – The nurse should explore
their past experience and use them to establish connections to new knowledge
d. Keep the learning session private and one-on-one – It is helpful when working
with older adult clients to invite another household member to the teaching
session so that person can help reinforce new information later. The nurse
should also honor the client’s preference for one-on-one or group settings.
9. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the
nurse recommend?
a. Walking briskly – weight bearing exercises are essential for maintaining bone
mass, which helps to prevent osteoporosis. Walking engages older adults in this
preventative and therapeutic strategies
b. Riding a bicycle
c. Performing isometric exercises
d. Engaging in high-impact aerobics
10. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The
nurse should identify that which of the following findings requires further intervention.
a. Erythema on pressure points – requires prompt relief of pressure and additional
measures to protect the skin from further breakdown
b. Lower extremity pulse strength of 2+ - expected finding
c. Fluid intake of 3000 mL per day – clients should drink 2.5-3L a day
d. A bowel movement every other day – bowel movements less frequent than
3x/week indicate constipation and need for intervention
11. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a
client. Which of the following actions should the nurse take?
