ATI Fundamentals
Version 3
1. A nurse is teaching a group of older adults about expected changes of aging.
Which of the following statements by a group member indicates that the
teaching has been effective?
"I should expect my heart rate to take longer to return to normal after
excessive as I get older."
2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which
of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
3. A nurse is planning care for a client who reports abdominal pain. An assessment
by the nurse reveals the client has a temperature of 39.2 degrees C (102
degrees F), heart rate of 105/min, a soft contender abdomen, and census
overdue by 2 days. Which of the following findings should be the nurse's
priority?
Temperature
4. A nurse is caring for a child who is postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day
and night.
5. A nurse is assessing the heart sounds of a client who has developed chest pain
that becomes worse wth inspiration. the nurse auscultates a high-pitched
scratching sound during both systole and diastole with diaphragm of the
stethoscope positioned at the left sternal border. Which of the following heart
sounds should the nurse document?
Pericardial friction rub
6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene.
Which of the following statements by the AP indicates an understanding of the
teaching?
"There are times I should use soap and water rather than alcohol based hand
rub to clean my hands."
7. A nurse is caring for a client who is unstable and has vital signs measured every
15 minutes by an electronic blood pressure machine. The nurse notices the
machine begins to measure the blood pressure at varied intervals and the
readings are inconsistent. Which of the following actions should the nurse take?
Discontinue the machine, and measure the blood pressure manually every
15 min.
, 8. A nurse is providing teaching to a client who has heart failure about how to
reduce his daily intake of sodium. Which of the following factors is the most
important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is
experiencing diarrhea and who might have a right ear infection. Which of the
following routes should the nurse use to obtain the temperature? Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which
of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client’s
11. A nurse on a medical-surgical unit is admitting a client. Which of the following
information should the nurse document in the client’s record first?
Assessment
12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing techniques?
The nurse washes with her hands held higher than her elbows.
13. A nurse at a screening clinic is assessing a client who reports a history of a heart
murmur related to aortic valve stenosis. At which of the following anatomical areas
should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the
chart.
15. A nurse is caring for an older adult client who becomes agitated when the nurse
requests the client’s dentures be removed prior to surgery. Which of the following
responses should the nurse make?
“What worries you about being without your teeth?”
16. A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurse’s religious beliefs related to death and dying. Which of the
following actions should the nurse take?
Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to
learning self-injection of insulin. Which of the following statements should the nurse
make?
“Tell me what I can do to help you overcome your fear of giving yourself
injections.”
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of
newly licensed nurses. Which of the following actions should the charge nurse teach as
the first response in CPR?
Version 3
1. A nurse is teaching a group of older adults about expected changes of aging.
Which of the following statements by a group member indicates that the
teaching has been effective?
"I should expect my heart rate to take longer to return to normal after
excessive as I get older."
2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which
of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
3. A nurse is planning care for a client who reports abdominal pain. An assessment
by the nurse reveals the client has a temperature of 39.2 degrees C (102
degrees F), heart rate of 105/min, a soft contender abdomen, and census
overdue by 2 days. Which of the following findings should be the nurse's
priority?
Temperature
4. A nurse is caring for a child who is postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day
and night.
5. A nurse is assessing the heart sounds of a client who has developed chest pain
that becomes worse wth inspiration. the nurse auscultates a high-pitched
scratching sound during both systole and diastole with diaphragm of the
stethoscope positioned at the left sternal border. Which of the following heart
sounds should the nurse document?
Pericardial friction rub
6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene.
Which of the following statements by the AP indicates an understanding of the
teaching?
"There are times I should use soap and water rather than alcohol based hand
rub to clean my hands."
7. A nurse is caring for a client who is unstable and has vital signs measured every
15 minutes by an electronic blood pressure machine. The nurse notices the
machine begins to measure the blood pressure at varied intervals and the
readings are inconsistent. Which of the following actions should the nurse take?
Discontinue the machine, and measure the blood pressure manually every
15 min.
, 8. A nurse is providing teaching to a client who has heart failure about how to
reduce his daily intake of sodium. Which of the following factors is the most
important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is
experiencing diarrhea and who might have a right ear infection. Which of the
following routes should the nurse use to obtain the temperature? Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which
of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client’s
11. A nurse on a medical-surgical unit is admitting a client. Which of the following
information should the nurse document in the client’s record first?
Assessment
12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing techniques?
The nurse washes with her hands held higher than her elbows.
13. A nurse at a screening clinic is assessing a client who reports a history of a heart
murmur related to aortic valve stenosis. At which of the following anatomical areas
should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the
chart.
15. A nurse is caring for an older adult client who becomes agitated when the nurse
requests the client’s dentures be removed prior to surgery. Which of the following
responses should the nurse make?
“What worries you about being without your teeth?”
16. A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurse’s religious beliefs related to death and dying. Which of the
following actions should the nurse take?
Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to
learning self-injection of insulin. Which of the following statements should the nurse
make?
“Tell me what I can do to help you overcome your fear of giving yourself
injections.”
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of
newly licensed nurses. Which of the following actions should the charge nurse teach as
the first response in CPR?
