ATI - Exam 1 fundamentals
A nurse is caring for a client who has an infection. The nurses should use which of the following
strategies to prevent the transmission of a client's infection. - ANS-Performing hand hygiene
before, during, and after direct contact with client
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's
chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should
recognize that this finding is suggestive of which of the following types of skin cancer. -
ANS-Basal cell carcinoma
A nurse is assessing a client's peripheral circulation. In which of the following locations should
the nurse palpate to assess the posterior tibial pulse? - ANS-The posterior tibial pulse is
located on the inner ankle, one-third of the way along the line between the tip of the medial
malleolus )end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm
higher, where it runs behind the medial malleolus.
A nurse is teaching a class of older adults about the expected physiologic changes of aging.
Which of the following changes should the nurse include in the discussion (select all that apply)
- ANS-More difficulty seeing due to the greater sensitivity to glare
Decreased cough reflex
Decreased bladder capacity
Dehydration of intervertebral disks
A nurse is preparing an educational program for a group of newly licensed nurses about client
confidentiality. The nurse should explain that curses may share a client's protected health
information with which of the following groups? - ANS-Health care team members caring for the
client
A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client
use of assistive devices during ambulation. Which of the following instructions should the nurse
give the APs about the clients' use of a cane? - ANS-"When the client moves, he should move
the cane forward first"
A nurse is caring for a client who refuses treatment and asked to be discharged from the
hospital against medical advise. The nurse notifies the client's provider, who tells the nurse to
restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands
taht restraining the client would be considered which type of civil action by the nurse? -
ANS-False imprisonment
The family of an older adult client brings him to the emergency department after finding him
wandering outside. During the initial assessment, the nurse notes that the client flinches when
she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the
following factors should the nurse identify as likely explanation for the client''s behavior? -
ANS-Confusion. Since the client was manifesting signs of confusion before coming to the
, emergency department and currently seems unable to understand or respond to speech the
nurse should determine that the client has confusion.
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of
the following precautions should the nurse include when creating a sigh to post outside the
client's room? - ANS-A protective mask is correct
A closed door is correct
A puncture-proof sharps container is correct
Hand hygiene is correct
A gown is incorrect
A nurse is receiving a provider's prescription for a client via telephone. Which of the following
actions should the nurse take to ensure the accuracy of the telephone prescription -
ANS-Repeat the order back to the provider.
Questions any part of the order that is unclear or inappropriate
Transcribe the order into the client's health record
A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on
the unit. As the nurse accepts the flowers, the messenger says. "I know Mrs. Welch from the
neighborhood. What happened to her?" Which of the following responses should the nurse
provide. - ANS-"It's my responsibility to remand you that we have to respect our clients privacy"
A charge nurse is anticipating the admission of four clients and planning their room
assignments. Which of the following clients should the nurse assign to the room closest to the
nurses' station? - ANS-A client who sustained a head injury and is having periods of confusion
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse
notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should
documents this as which of the following types of wounds? - ANS-Laceration
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing
the onset of manifestations. Which of the following client statements should indicate to the nurse
the need for additional teaching? - ANS-"I will take my medications at the first sign of an
attack."
A nurse is planning care for a client who has a decreased level of consciousness. The client is
receiving continuous enteral feedings via a gastronomy tube due to an inability to swallow.
Which of the following is the priority action by the nurse? - ANS-Elevate the head of the client's
bed 30 to 45 degrees
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following
actions should the nurse take? - ANS-Secure the restraints using a quick-release tie.
A nurse in a long-term care facility is planning care for several clients. Which of the following
activities should the nurse delegate to the licensed practical nurse (LPN)? - ANS-Scheduling a
diagnostic study for a client.
A nurse is planning care for a client who requires precautions. Which of the following actions
should the nurse take? - ANS-The nurse should wear an N95 respirator mask.
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal
deformities should the nurse expect to find in this client? - ANS-Kyphosis
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy.
Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg. and
A nurse is caring for a client who has an infection. The nurses should use which of the following
strategies to prevent the transmission of a client's infection. - ANS-Performing hand hygiene
before, during, and after direct contact with client
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's
chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should
recognize that this finding is suggestive of which of the following types of skin cancer. -
ANS-Basal cell carcinoma
A nurse is assessing a client's peripheral circulation. In which of the following locations should
the nurse palpate to assess the posterior tibial pulse? - ANS-The posterior tibial pulse is
located on the inner ankle, one-third of the way along the line between the tip of the medial
malleolus )end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm
higher, where it runs behind the medial malleolus.
A nurse is teaching a class of older adults about the expected physiologic changes of aging.
Which of the following changes should the nurse include in the discussion (select all that apply)
- ANS-More difficulty seeing due to the greater sensitivity to glare
Decreased cough reflex
Decreased bladder capacity
Dehydration of intervertebral disks
A nurse is preparing an educational program for a group of newly licensed nurses about client
confidentiality. The nurse should explain that curses may share a client's protected health
information with which of the following groups? - ANS-Health care team members caring for the
client
A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client
use of assistive devices during ambulation. Which of the following instructions should the nurse
give the APs about the clients' use of a cane? - ANS-"When the client moves, he should move
the cane forward first"
A nurse is caring for a client who refuses treatment and asked to be discharged from the
hospital against medical advise. The nurse notifies the client's provider, who tells the nurse to
restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands
taht restraining the client would be considered which type of civil action by the nurse? -
ANS-False imprisonment
The family of an older adult client brings him to the emergency department after finding him
wandering outside. During the initial assessment, the nurse notes that the client flinches when
she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the
following factors should the nurse identify as likely explanation for the client''s behavior? -
ANS-Confusion. Since the client was manifesting signs of confusion before coming to the
, emergency department and currently seems unable to understand or respond to speech the
nurse should determine that the client has confusion.
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of
the following precautions should the nurse include when creating a sigh to post outside the
client's room? - ANS-A protective mask is correct
A closed door is correct
A puncture-proof sharps container is correct
Hand hygiene is correct
A gown is incorrect
A nurse is receiving a provider's prescription for a client via telephone. Which of the following
actions should the nurse take to ensure the accuracy of the telephone prescription -
ANS-Repeat the order back to the provider.
Questions any part of the order that is unclear or inappropriate
Transcribe the order into the client's health record
A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on
the unit. As the nurse accepts the flowers, the messenger says. "I know Mrs. Welch from the
neighborhood. What happened to her?" Which of the following responses should the nurse
provide. - ANS-"It's my responsibility to remand you that we have to respect our clients privacy"
A charge nurse is anticipating the admission of four clients and planning their room
assignments. Which of the following clients should the nurse assign to the room closest to the
nurses' station? - ANS-A client who sustained a head injury and is having periods of confusion
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse
notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should
documents this as which of the following types of wounds? - ANS-Laceration
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing
the onset of manifestations. Which of the following client statements should indicate to the nurse
the need for additional teaching? - ANS-"I will take my medications at the first sign of an
attack."
A nurse is planning care for a client who has a decreased level of consciousness. The client is
receiving continuous enteral feedings via a gastronomy tube due to an inability to swallow.
Which of the following is the priority action by the nurse? - ANS-Elevate the head of the client's
bed 30 to 45 degrees
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following
actions should the nurse take? - ANS-Secure the restraints using a quick-release tie.
A nurse in a long-term care facility is planning care for several clients. Which of the following
activities should the nurse delegate to the licensed practical nurse (LPN)? - ANS-Scheduling a
diagnostic study for a client.
A nurse is planning care for a client who requires precautions. Which of the following actions
should the nurse take? - ANS-The nurse should wear an N95 respirator mask.
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal
deformities should the nurse expect to find in this client? - ANS-Kyphosis
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy.
Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg. and
