ATI FINAL EXAM TEST
1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The
nurse understands that the most important aspect of hand hygiene is the amount of
Friction
2. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the
client may be unprepared to learn if the client
reports severe pain.
3. A client comes to the emergency department reporting that he has had diarrhea for 4 days
and is urinating less than usual. When assessing the client’s skin turgor, the nurse should
grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.
4. A nurse is planning interventions for a group of clients who are obese. What can the
nurse do to improve their commitment to a long term goal of weight loss?
Attempt to develop the clients’ self-motivation.
5. When admitting a client, the nurse records which information in the client’s record first?
Assessment of the client
6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be
upset about the IV catheter insertion, but says nothing to the nurse. Which of the
following of the following is an appropriate nursing response?
"Is there something about this procedure that concerns you?"
7. A client who is unstable and requires frequent vital signs has an electronic blood pressure
machine automatically measuring his blood pressure every 15 min. However, the
machine is reading the client’s blood pressure at more frequent intervals, and the readings
are not similar. The nurse checks the machine settings and observes the additional
readings, but the problem continues. Which of the following is the appropriate nursing
action?
Disconnect the machine, and measure the blood pressure manually every 15 min.
8. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is
resistant to learning self injection of insulin and asks the nurse to administer all the
injections. The nurse explains the importance of learning self care and appropriately adds
which of the following statements?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
9. An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or
four times a day. I get angry, and I think that the client is doing it just to get attention. I
think we should put adult diapers on her." Which is the appropriate nursing response?
"It is very upsetting to see an adult client regress."
10. A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated
that a moderate amount of blood loss is expected during the surgery, and the neighbor is
anxious about acquiring an infection from a blood transfusion. Which of the following is
appropriate for the nurse to suggest?
Donating autologous blood before the surgery
11. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart
murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the
stethoscope at which location?
, Second intercostal space to the right of the sternum.
12. A client is admitted to the hospital with decreased circulation in the left leg. During the
admission assessment, which is the most important nursing action initially?
Evaluate the pedal pulses.
13. A nurse is caring for a client who requires rectal temperature monitoring. Available at the
client's bedside is a thermometer is with a long, slender tip. Which of the following is the
appropriate action for the nurse to take?
Obtain a thermometer with a short, blunt insertion end.
14. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of
sodium and cholesterol. The nurse understands that the most significant factor in
planning dietary changes for this client is the
involvement of the client in planning the change.
15. A nurse is caring for an older adult client who is confused and continually grabs at the
nurses. Which of the following is an nursing action?
Firmly tell him to not grab
16. An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure
cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?"
The nurse replies that taking the blood pressure of a morbidly obese client with a regular
blood pressure cuff will result in a reading that is
high
17. Which of the following should the nurse do first when preparing to provide tracheostomy
care?
Perform hand hygiene.
18. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The
client returns from the post anesthesia care crying, but awake, from the recovery room.
Which approach is likely to be successful?
Examine the mouth last.
19. A nurse admits a client to a same-day surgery center for an exploratory laparotomy
procedure this morning. The client’s surgeon asks the nurse to witness the signing of the
preoperative consent form. In signing the form as a witness, the nurse affirms that
the signature on the preoperative consent form is the client's.
20. To use proper body mechanics while making an occupied bed for a client on bed rest, the
nurse should
place the bed in a high horizontal position.
21. Which of the following should a group of community health nurses plan as part of a
primary prevention program for occupational pulmonary diseases?
Elimination of the exposure
22. When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of
the following assessment findings prior to beginning chest compressions?
Absence of pulse
23. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a
back injury, which of the following techniques should the nurse use?
Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on
the nurse’s shoulders, and the nurse’s hands under the client’s axillae.
1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The
nurse understands that the most important aspect of hand hygiene is the amount of
Friction
2. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the
client may be unprepared to learn if the client
reports severe pain.
3. A client comes to the emergency department reporting that he has had diarrhea for 4 days
and is urinating less than usual. When assessing the client’s skin turgor, the nurse should
grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.
4. A nurse is planning interventions for a group of clients who are obese. What can the
nurse do to improve their commitment to a long term goal of weight loss?
Attempt to develop the clients’ self-motivation.
5. When admitting a client, the nurse records which information in the client’s record first?
Assessment of the client
6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be
upset about the IV catheter insertion, but says nothing to the nurse. Which of the
following of the following is an appropriate nursing response?
"Is there something about this procedure that concerns you?"
7. A client who is unstable and requires frequent vital signs has an electronic blood pressure
machine automatically measuring his blood pressure every 15 min. However, the
machine is reading the client’s blood pressure at more frequent intervals, and the readings
are not similar. The nurse checks the machine settings and observes the additional
readings, but the problem continues. Which of the following is the appropriate nursing
action?
Disconnect the machine, and measure the blood pressure manually every 15 min.
8. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is
resistant to learning self injection of insulin and asks the nurse to administer all the
injections. The nurse explains the importance of learning self care and appropriately adds
which of the following statements?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
9. An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or
four times a day. I get angry, and I think that the client is doing it just to get attention. I
think we should put adult diapers on her." Which is the appropriate nursing response?
"It is very upsetting to see an adult client regress."
10. A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated
that a moderate amount of blood loss is expected during the surgery, and the neighbor is
anxious about acquiring an infection from a blood transfusion. Which of the following is
appropriate for the nurse to suggest?
Donating autologous blood before the surgery
11. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart
murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the
stethoscope at which location?
, Second intercostal space to the right of the sternum.
12. A client is admitted to the hospital with decreased circulation in the left leg. During the
admission assessment, which is the most important nursing action initially?
Evaluate the pedal pulses.
13. A nurse is caring for a client who requires rectal temperature monitoring. Available at the
client's bedside is a thermometer is with a long, slender tip. Which of the following is the
appropriate action for the nurse to take?
Obtain a thermometer with a short, blunt insertion end.
14. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of
sodium and cholesterol. The nurse understands that the most significant factor in
planning dietary changes for this client is the
involvement of the client in planning the change.
15. A nurse is caring for an older adult client who is confused and continually grabs at the
nurses. Which of the following is an nursing action?
Firmly tell him to not grab
16. An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure
cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?"
The nurse replies that taking the blood pressure of a morbidly obese client with a regular
blood pressure cuff will result in a reading that is
high
17. Which of the following should the nurse do first when preparing to provide tracheostomy
care?
Perform hand hygiene.
18. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The
client returns from the post anesthesia care crying, but awake, from the recovery room.
Which approach is likely to be successful?
Examine the mouth last.
19. A nurse admits a client to a same-day surgery center for an exploratory laparotomy
procedure this morning. The client’s surgeon asks the nurse to witness the signing of the
preoperative consent form. In signing the form as a witness, the nurse affirms that
the signature on the preoperative consent form is the client's.
20. To use proper body mechanics while making an occupied bed for a client on bed rest, the
nurse should
place the bed in a high horizontal position.
21. Which of the following should a group of community health nurses plan as part of a
primary prevention program for occupational pulmonary diseases?
Elimination of the exposure
22. When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of
the following assessment findings prior to beginning chest compressions?
Absence of pulse
23. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a
back injury, which of the following techniques should the nurse use?
Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on
the nurse’s shoulders, and the nurse’s hands under the client’s axillae.
