NURSING
ATI FUNDAMENTALS (HEALTH ASSESSMENT) COMPLETE EXAM COMPLETE
PRACTICE QUESTIONS AND ANSWERS A GRADED EXAM
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following
actions should the nurse take first?
A) Evaluate pedal pulses
B) Obtain medical Hx
C) Measure vital signs
D) Assess for leg pain - CORRECT ANSWER A) Evaluate pedal pulses
For a client w/ decreased circulation in the leg, evaluating pedal pulses is critical in order to
determine adequate blood supply to the foot. THe nurse should apply the safety and risk
reduction priority-setting framework. This framework assigns priority to the factor posing the
greatest safety risk to the client. When there are several risks to client safety, the one posing
the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs,
the ABC priority setting framework, and/or nursing knowledge to ID which risk poses the
greatest threat to the client.
The nurse is performing a neuro assessment of a client. To promote safety during the exam, the
nurse stands nearby as the client follows instructions for which of the following tests?
A) Romberg
B) Kinesthetic sensation
C) 2-point discrimination
D) Weber - CORRECT ANSWER A) Romberg
A Romberg test evaluates standing balance, first with the client's eyes open and then with them
closed. The nurses should remain nearby because the client could fall during this test.
A nurse is performing an admission assessment for a client who has asthma and reports several
food allergies. Which of the following actions should the nurse take first?
A) Document the client's food allergies in the medical record
B) Ask the client to ID the specific food allergies
C) Monitor the client for indications for anaphylaxis
D) Have epinephrine available for administration - CORRECT ANSWER B) Ask the client to ID the
specific food allergies
The nurse should apply the nursing process for priority-setting framework in order to plan client
care and prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginning with an assessment or data collection. Before the nurse can formulate a plan of
action, implement a nursing intervention, or notify the provider of a change in the client's
status, the nurse must first collect adequate data from the client. Assessing or collecting
,additional data will provide the nurse with the knowledge to make an appropriate decision.
Therefore, the nurse should first assess the clients allergies and ID the specific allergens to
ensure the specific foods are not offered to the client during meals.
A nurse is measuring the client's vital signs and notices an irregularity in the pulse. Which of the
following actions should the nurse take?
A) Measure the pulse using a Doppler ultrasound stethoscope
B) Check the client's pedal pulses
C) Count the apical pulse rate for 1 full minute and describe the rhythm in the chart
D) Take the pulse at each peripheral site and count the rate for 30 seconds - CORRECT ANSWER
C) Count the apical pulse rate for 1 full minute and describe the rythem in the chart
If the peripheral pulse rate is irregular, the nurse should auscultate the apical pulse for 60
seconds to obtain an accurate rate. THen, the nurse should document the irregularity in the
client's medical record.
A nurse is assessing a client's respiratory system. Which of the following breath sounds should
the nurse expect to hear over the periphery of the major lung sounds?
A) Vesicular
B) Bronchial
C) Rhonchi
D) Bronchovesicular - CORRECT ANSWER A) Vesicular
The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds
are soft and low-pitched.
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify
as outside the expected reference range?
A) Pulse rate of 90/min
B) Rectal temperature 38C (1004F)
C) Pulse oximetry 95%
D) BP 145/90 mmHg - CORRECT ANSWER D) BP 145/90 mmHg
This blood pressure is greater than the expected reference range and should be reported to the
provider.
A nurse in a provider's office is assessing a client who has HF. The client has gained weight since
her last visit, and her ankles are edematous. Which of the following findings is another clinical
manifestation of fluid volume excess?
A) Sunken eyeballs
,B) Hypotension
C) Poor skin turgor
D) Bounding pulse - CORRECT ANSWER D) Bounding pulse
A bounding pulse is an expected finding of fluid volume excess.
A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which
of the following actions should the nurse take next?
A) Document the finding
B) Measure the client's apical pulse rate
C) Talk to the client about factors that can affect the pulse rate
D) Notify the provider about the client's radial pulse rate - CORRECT ANSWER B) Measure the
client's apical pulse rate
The first action the nurse should take using the nursing process is to assess or collect data from
the client. This pulse rate is below the expected reference range for an adult. The nurse and a
coworker should measure the apical and radial pulse rates simultaneously to determine if there
is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might
have a cardiovascular disorder.
A nurse is assessing the client's peripheral pulses. Which of the following descriptions should
the nurse use to document the findings?
A) Peripheral pulses equal and bilaterally at a rate of 60/min
B) Radial, brachial, and pedal pulses bilaterally weak
C) Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
D) Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable -
CORRECT ANSWER C) Peripheral pulses bilaterally symmetric, equal, and strong in all 4
extremities
The nurse does not evaluate the peripheral pulses routinely when measuring vital signs.
Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to
an extremity or during a comprehensive physical examination. A full evaluation of peripheral
pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and
dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include strength of
pulsations as well as their equality and symmetry in all 4 extremities.
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse
reveals the client has a temp of 39.2*C (102.6*F), a heart rate of 105/min, a soft nontender
abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's
priority?
A) Heart rate of 105/min
, B) Soft nontender abdomen
C) Temperature
D) Overdue menses - CORRECT ANSWER C) Temperature
Elevated temperature is an emergent physiological need that requires priority intervention by
the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of
priority. The levels are as follows: physiological needs, safety, and security needs, love and
belonging needs, personal achievement and self-esteem needs, and achievement of full
potential and the ability to problem-solve and cope with life situations.
When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first
before following the remaining four levels. However, it is important for the nurse to consider all
contributing client factors, as higher levels of the pyramid can compete with those at the lower
levels, depending on the situation.
A nurse is performing a breast examination for a female client. Which of the following
techniques should the nurse use first?
A) Inspect both breasts simultaneously
B) Squeeze the nipples
C) Palpate the breast and tail of Spence
D) Palpate the axillary lymph nodes - CORRECT ANSWER A) Inspect both breasts simultaneously
According to evidence-based practice, the nurse should first inspect both breasts with the
client's arms in several different positions to look for asymmetry, masses, retraction, lesions,
inflammation, and dimpling.
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin.
Which of the following questions should the nurse ask to encourage discussion with the client?
A) "Does the medication you're taking relieve pain?"
B) "Can you point to where the pain is the worst?"
C) "What do you think caused the onset of your pain?"
D) "Changing positions makes your pain worse, right?" - CORRECT ANSWER C) "What do you
think caused the onset of your pain?"
The nurse is using an open-ended question that allows the client to respond with a wide range
of information by using more than a few words.
After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that
the nurse observed an indentation of which of the following depths after applying pressure?
A) 2 mm
B) 4 mm
ATI FUNDAMENTALS (HEALTH ASSESSMENT) COMPLETE EXAM COMPLETE
PRACTICE QUESTIONS AND ANSWERS A GRADED EXAM
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following
actions should the nurse take first?
A) Evaluate pedal pulses
B) Obtain medical Hx
C) Measure vital signs
D) Assess for leg pain - CORRECT ANSWER A) Evaluate pedal pulses
For a client w/ decreased circulation in the leg, evaluating pedal pulses is critical in order to
determine adequate blood supply to the foot. THe nurse should apply the safety and risk
reduction priority-setting framework. This framework assigns priority to the factor posing the
greatest safety risk to the client. When there are several risks to client safety, the one posing
the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs,
the ABC priority setting framework, and/or nursing knowledge to ID which risk poses the
greatest threat to the client.
The nurse is performing a neuro assessment of a client. To promote safety during the exam, the
nurse stands nearby as the client follows instructions for which of the following tests?
A) Romberg
B) Kinesthetic sensation
C) 2-point discrimination
D) Weber - CORRECT ANSWER A) Romberg
A Romberg test evaluates standing balance, first with the client's eyes open and then with them
closed. The nurses should remain nearby because the client could fall during this test.
A nurse is performing an admission assessment for a client who has asthma and reports several
food allergies. Which of the following actions should the nurse take first?
A) Document the client's food allergies in the medical record
B) Ask the client to ID the specific food allergies
C) Monitor the client for indications for anaphylaxis
D) Have epinephrine available for administration - CORRECT ANSWER B) Ask the client to ID the
specific food allergies
The nurse should apply the nursing process for priority-setting framework in order to plan client
care and prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginning with an assessment or data collection. Before the nurse can formulate a plan of
action, implement a nursing intervention, or notify the provider of a change in the client's
status, the nurse must first collect adequate data from the client. Assessing or collecting
,additional data will provide the nurse with the knowledge to make an appropriate decision.
Therefore, the nurse should first assess the clients allergies and ID the specific allergens to
ensure the specific foods are not offered to the client during meals.
A nurse is measuring the client's vital signs and notices an irregularity in the pulse. Which of the
following actions should the nurse take?
A) Measure the pulse using a Doppler ultrasound stethoscope
B) Check the client's pedal pulses
C) Count the apical pulse rate for 1 full minute and describe the rhythm in the chart
D) Take the pulse at each peripheral site and count the rate for 30 seconds - CORRECT ANSWER
C) Count the apical pulse rate for 1 full minute and describe the rythem in the chart
If the peripheral pulse rate is irregular, the nurse should auscultate the apical pulse for 60
seconds to obtain an accurate rate. THen, the nurse should document the irregularity in the
client's medical record.
A nurse is assessing a client's respiratory system. Which of the following breath sounds should
the nurse expect to hear over the periphery of the major lung sounds?
A) Vesicular
B) Bronchial
C) Rhonchi
D) Bronchovesicular - CORRECT ANSWER A) Vesicular
The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds
are soft and low-pitched.
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify
as outside the expected reference range?
A) Pulse rate of 90/min
B) Rectal temperature 38C (1004F)
C) Pulse oximetry 95%
D) BP 145/90 mmHg - CORRECT ANSWER D) BP 145/90 mmHg
This blood pressure is greater than the expected reference range and should be reported to the
provider.
A nurse in a provider's office is assessing a client who has HF. The client has gained weight since
her last visit, and her ankles are edematous. Which of the following findings is another clinical
manifestation of fluid volume excess?
A) Sunken eyeballs
,B) Hypotension
C) Poor skin turgor
D) Bounding pulse - CORRECT ANSWER D) Bounding pulse
A bounding pulse is an expected finding of fluid volume excess.
A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which
of the following actions should the nurse take next?
A) Document the finding
B) Measure the client's apical pulse rate
C) Talk to the client about factors that can affect the pulse rate
D) Notify the provider about the client's radial pulse rate - CORRECT ANSWER B) Measure the
client's apical pulse rate
The first action the nurse should take using the nursing process is to assess or collect data from
the client. This pulse rate is below the expected reference range for an adult. The nurse and a
coworker should measure the apical and radial pulse rates simultaneously to determine if there
is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might
have a cardiovascular disorder.
A nurse is assessing the client's peripheral pulses. Which of the following descriptions should
the nurse use to document the findings?
A) Peripheral pulses equal and bilaterally at a rate of 60/min
B) Radial, brachial, and pedal pulses bilaterally weak
C) Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
D) Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable -
CORRECT ANSWER C) Peripheral pulses bilaterally symmetric, equal, and strong in all 4
extremities
The nurse does not evaluate the peripheral pulses routinely when measuring vital signs.
Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to
an extremity or during a comprehensive physical examination. A full evaluation of peripheral
pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and
dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include strength of
pulsations as well as their equality and symmetry in all 4 extremities.
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse
reveals the client has a temp of 39.2*C (102.6*F), a heart rate of 105/min, a soft nontender
abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's
priority?
A) Heart rate of 105/min
, B) Soft nontender abdomen
C) Temperature
D) Overdue menses - CORRECT ANSWER C) Temperature
Elevated temperature is an emergent physiological need that requires priority intervention by
the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of
priority. The levels are as follows: physiological needs, safety, and security needs, love and
belonging needs, personal achievement and self-esteem needs, and achievement of full
potential and the ability to problem-solve and cope with life situations.
When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first
before following the remaining four levels. However, it is important for the nurse to consider all
contributing client factors, as higher levels of the pyramid can compete with those at the lower
levels, depending on the situation.
A nurse is performing a breast examination for a female client. Which of the following
techniques should the nurse use first?
A) Inspect both breasts simultaneously
B) Squeeze the nipples
C) Palpate the breast and tail of Spence
D) Palpate the axillary lymph nodes - CORRECT ANSWER A) Inspect both breasts simultaneously
According to evidence-based practice, the nurse should first inspect both breasts with the
client's arms in several different positions to look for asymmetry, masses, retraction, lesions,
inflammation, and dimpling.
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin.
Which of the following questions should the nurse ask to encourage discussion with the client?
A) "Does the medication you're taking relieve pain?"
B) "Can you point to where the pain is the worst?"
C) "What do you think caused the onset of your pain?"
D) "Changing positions makes your pain worse, right?" - CORRECT ANSWER C) "What do you
think caused the onset of your pain?"
The nurse is using an open-ended question that allows the client to respond with a wide range
of information by using more than a few words.
After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that
the nurse observed an indentation of which of the following depths after applying pressure?
A) 2 mm
B) 4 mm
