RN ATI CONCEPT-BASED ASSESSMENT PROCTORED
EXAM FOR LEVEL 1 FULLY ANSWERED WITH
RATIONALES
• A nurse is admitting a client who has pulmonary tuberculosis. Which of
thefollowing transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by
airborne droplets smaller than 5 microns in diameter. Therefore, this
clientrequires airborne precautions to prevent communicating this
infection to others
• A nurse in a mental health facility is preparing an educational program for a
groupof staff nurses about the proper use of restraints. Which of the following
information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may
be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are
limitedto 2 hr and children who are younger than 9 years old are limited to 1
hr
• A nurse is teaching sleep hygiene to a client who has insomnia. Which of
thefollowing statements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular,psychological, and musculoskeletal health. The nurse should
recommend that the client avoid exercising within 2 hr of bedtime to limit
stimulation and enhance sleep
• A nurse is preparing to leave the room of a client who is on isolation
precautions. Which of the following actions should the nurse take when
removing a tied surgicalmask?
• Remove the mask by securely holding the ties and moving it away from the face
• Rationale: The nurse should untie the bottom strings and then the top
strings.Finally, while still holding the strings, the nurse should remove the
mask fromher face. This action prevents the nurse from touching the front
of the mask, which is contaminated
• A nurse is caring for an adolescent client who is in critical condition following a
motorvehicle crash in which he was the passenger. The client's parent shouts at
the nurse, asking why her son is dying instead of the driver. Which of the following
actions should the nurse take to provide emotional support to the parent?
, • Inform the parent that anger is a natural response when dealing with loss
• Rationale: The nurse should identify that the parent is in the anger stage of
grief. The nurse should assist the parent to understand that anger is a natural
response to loss and encourage her to talk about her feelings
• A community health nurse is planning prevention strategies for hypertension
amongmembers of her community. The nurse should identify that which of the
following ethnic groups in the community is at greatest risk of developing
hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-
American ethnicity have the highest prevalence of hypertension. Therefore,
thenurse should identify community members of this ethnicity are at
greatest risk of developing hypertension.
• A community health nurse is planning interventions to promote Healthy People
2020 initiatives in the community. Which of the following actions should the nurse
plan to take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a Healthy
People 2020 initiative. Using the nursing process, the first action the nurse
should take is to assess the needs of the community. By identifying disparities
in community health, the nurse can develop interventions targeted at the
community's specificneeds.
• A nurse is reviewing a client's new prescriptions that were just documented in
the client's medical record by the provider. Which of the following abbreviations
shouldthe nurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the provider. The
abbreviations "SQ" and "QD" are considered error-prone and should not be
used in documentation. The nurse should clarify that the provider intends
theprescription to be administered subcutaneously once daily.
"Subcutaneous" or"subcut" should be used instead of "SQ" and "daily"
should be used instead of"QD."
• A nurse is talking with a client who has major depressive disorder. The client states,
"Nobody cares if I'm around or not." Which of the following responses should the
nursetake?
• It sounds as though you’re feeling hopeless
• Rationale: This statement by the nurse is an example of restating, which
isa therapeutic response. This technique restates the main idea the
client has expressed and allows the client to clarify any
misunderstanding.
, • A nurse is preparing to administer a unit of packed RBCs to a client. In
adherencewith the Joint Commission National Patient Safety Goals regarding
blood administration, which of the following actions should the nurse plan to
take?
• Verify the client and blood component using a two-person process
• Rationale: The Joint Commission National Patient Safety Goals regarding
bloodtransfusions includes improving the accuracy of client identification.
The nurseshould eliminate transfusion errors related to client
misidentification by using atwo-person verification process to identify the
client and the blood component.
• A nurse on a medical-surgical unit is caring for a group of clients. Which of
the following clients should the nurse monitor for the development of reflex
urinaryincontinence?
• A client who has a T12 spinal cord injury
• Rationale: The nurse should identify that a client who has a C1 to S2 spinal
cordinjury is at risk of developing reflex urinary incontinence. With this type
of incontinence, the client is unaware that the bladder is full and therefore
lacks the urge to void, resulting in the involuntary loss of urine. The nurse
should monitor for this form of incontinence and implement interventions
such as intermittent catheterization.
• A nurse is documenting an assessment in a client's electronic health record when
an assistive personnel (AP) asks to enter the morning blood glucose for the client.
Whichof the following actions should the nurse take?
• Request that the AP use another computer to enter the data
• Rationale: The nurse should request that the AP to go to another
computerthat is not in use to enter the morning blood glucose from the
client. This istime- sensitive data that needs to be entered in the
computer as soon as possible.
• A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available
isacetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use
a trailing zero.)
• 1.2 mL
• Rationale:
Ratio and Proportion
• STEP 1: What is the unit of measurement the nurse should calculate? mL
• STEP 2: What is the dose the nurse should administer? Dose to administer
= Desired 120 mg
• STEP 3: What is the dose available? Dose available = Have 80 mg
• STEP 4: Should the nurse convert the units of measurement? No
EXAM FOR LEVEL 1 FULLY ANSWERED WITH
RATIONALES
• A nurse is admitting a client who has pulmonary tuberculosis. Which of
thefollowing transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by
airborne droplets smaller than 5 microns in diameter. Therefore, this
clientrequires airborne precautions to prevent communicating this
infection to others
• A nurse in a mental health facility is preparing an educational program for a
groupof staff nurses about the proper use of restraints. Which of the following
information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may
be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are
limitedto 2 hr and children who are younger than 9 years old are limited to 1
hr
• A nurse is teaching sleep hygiene to a client who has insomnia. Which of
thefollowing statements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular,psychological, and musculoskeletal health. The nurse should
recommend that the client avoid exercising within 2 hr of bedtime to limit
stimulation and enhance sleep
• A nurse is preparing to leave the room of a client who is on isolation
precautions. Which of the following actions should the nurse take when
removing a tied surgicalmask?
• Remove the mask by securely holding the ties and moving it away from the face
• Rationale: The nurse should untie the bottom strings and then the top
strings.Finally, while still holding the strings, the nurse should remove the
mask fromher face. This action prevents the nurse from touching the front
of the mask, which is contaminated
• A nurse is caring for an adolescent client who is in critical condition following a
motorvehicle crash in which he was the passenger. The client's parent shouts at
the nurse, asking why her son is dying instead of the driver. Which of the following
actions should the nurse take to provide emotional support to the parent?
, • Inform the parent that anger is a natural response when dealing with loss
• Rationale: The nurse should identify that the parent is in the anger stage of
grief. The nurse should assist the parent to understand that anger is a natural
response to loss and encourage her to talk about her feelings
• A community health nurse is planning prevention strategies for hypertension
amongmembers of her community. The nurse should identify that which of the
following ethnic groups in the community is at greatest risk of developing
hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-
American ethnicity have the highest prevalence of hypertension. Therefore,
thenurse should identify community members of this ethnicity are at
greatest risk of developing hypertension.
• A community health nurse is planning interventions to promote Healthy People
2020 initiatives in the community. Which of the following actions should the nurse
plan to take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a Healthy
People 2020 initiative. Using the nursing process, the first action the nurse
should take is to assess the needs of the community. By identifying disparities
in community health, the nurse can develop interventions targeted at the
community's specificneeds.
• A nurse is reviewing a client's new prescriptions that were just documented in
the client's medical record by the provider. Which of the following abbreviations
shouldthe nurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the provider. The
abbreviations "SQ" and "QD" are considered error-prone and should not be
used in documentation. The nurse should clarify that the provider intends
theprescription to be administered subcutaneously once daily.
"Subcutaneous" or"subcut" should be used instead of "SQ" and "daily"
should be used instead of"QD."
• A nurse is talking with a client who has major depressive disorder. The client states,
"Nobody cares if I'm around or not." Which of the following responses should the
nursetake?
• It sounds as though you’re feeling hopeless
• Rationale: This statement by the nurse is an example of restating, which
isa therapeutic response. This technique restates the main idea the
client has expressed and allows the client to clarify any
misunderstanding.
, • A nurse is preparing to administer a unit of packed RBCs to a client. In
adherencewith the Joint Commission National Patient Safety Goals regarding
blood administration, which of the following actions should the nurse plan to
take?
• Verify the client and blood component using a two-person process
• Rationale: The Joint Commission National Patient Safety Goals regarding
bloodtransfusions includes improving the accuracy of client identification.
The nurseshould eliminate transfusion errors related to client
misidentification by using atwo-person verification process to identify the
client and the blood component.
• A nurse on a medical-surgical unit is caring for a group of clients. Which of
the following clients should the nurse monitor for the development of reflex
urinaryincontinence?
• A client who has a T12 spinal cord injury
• Rationale: The nurse should identify that a client who has a C1 to S2 spinal
cordinjury is at risk of developing reflex urinary incontinence. With this type
of incontinence, the client is unaware that the bladder is full and therefore
lacks the urge to void, resulting in the involuntary loss of urine. The nurse
should monitor for this form of incontinence and implement interventions
such as intermittent catheterization.
• A nurse is documenting an assessment in a client's electronic health record when
an assistive personnel (AP) asks to enter the morning blood glucose for the client.
Whichof the following actions should the nurse take?
• Request that the AP use another computer to enter the data
• Rationale: The nurse should request that the AP to go to another
computerthat is not in use to enter the morning blood glucose from the
client. This istime- sensitive data that needs to be entered in the
computer as soon as possible.
• A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available
isacetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use
a trailing zero.)
• 1.2 mL
• Rationale:
Ratio and Proportion
• STEP 1: What is the unit of measurement the nurse should calculate? mL
• STEP 2: What is the dose the nurse should administer? Dose to administer
= Desired 120 mg
• STEP 3: What is the dose available? Dose available = Have 80 mg
• STEP 4: Should the nurse convert the units of measurement? No
