ATI Fundamentals - Practice A
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse
identify as an indication of correct use? - ANS-The client holds the cane on the stronger side of
her body.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr.
When the nurse performs the initial assessment, he notes that the client has received only 80
mL over the last 2 hr. Which of the following actions should the nurse take first? - ANS-Check
the IV tubing for obstruction.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the
following actions should the nurse take when inserting the NG tube? - ANS-Have the client take
sips of water to promote insertion of the NG tube into the esophagus.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should
the nurse report to the provider? - ANS-Potassium 5.4 mEq/L
A nurse is providing discharge instructions to a client who will be using a walker. Which of the
following statements indicates an understanding of the teaching? - ANS-"I will hire someone to
trim the tree that hangs low over the stairs of my front porch."
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia.
Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all
that apply.) - ANS-assist the client with a partial bed bath, measure the client's BP after the
nurse administers an antihypertensive medication, use a communication board to ask what the
client wants for lunch
A nurse is caring for a client who is expressing anger about the diagnosis of colorectal cancer.
Which of the following actions should the nurse take? - ANS-Reassure the client that this is an
expected response to grief.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of
the following types of dressing should the nurse use? - ANS-Hydrocolloid
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear. - ANS-Press
gently on the tragus of the client's ear.
, A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
Which of the following actions should the nurse take? - ANS-Subtract the amount of irrigant
used from the client's urine output.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client? - ANS-Make
sure the client wears a mask when outside her room if there is construction in the area.
A nurse is auscultating the anterior chest of a client who was newly admitted to a
medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the
stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the
clip.) - ANS-Normal breath sounds
A nurse is planning strategies to manage time effectively for client care. Which of the following
strategies should the nurse implement? - ANS-Use the planning step of the nursing process to
prioritize client care delivery.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the
use of thigh-length sequential compression sleeves. Which of the following actions should the
nurse take? - ANS-Make sure two fingers can fit under the sleeves.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques
should the nurse use when performing nasotracheal suctioning for the client? - ANS-Apply
intermittent suction when withdrawing the catheter.
A nurse is assessing a client who reports increased pain following physical therapy. Which of
the following questions should the nurse ask when assessing the quality of the client's pain? -
ANS-"Is your pain sharp or dull?"
A nurse is providing discharge teaching to a client about self-administering heparin. Which of
the following instruction should the nurse include in the teaching? - ANS-Administer the
medication into the abdomen.
A nurse is a long-term care facility is caring for a client who dies during the nurse's shift. Identify
the sequence in which the nurse should perform the following steps. (Move the steps into the
box on the right, placing them in the order of performance. Use all the steps.) - ANS-Obtain the
pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the
client's body. Ask the client's family members if they would like to view the body. Place a name
tag on the body.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home.
Which of the following instructions should the nurse include in teaching? - ANS-Use
tracheostomy covers when outdoors.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse
identify as an indication of correct use? - ANS-The client holds the cane on the stronger side of
her body.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr.
When the nurse performs the initial assessment, he notes that the client has received only 80
mL over the last 2 hr. Which of the following actions should the nurse take first? - ANS-Check
the IV tubing for obstruction.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the
following actions should the nurse take when inserting the NG tube? - ANS-Have the client take
sips of water to promote insertion of the NG tube into the esophagus.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should
the nurse report to the provider? - ANS-Potassium 5.4 mEq/L
A nurse is providing discharge instructions to a client who will be using a walker. Which of the
following statements indicates an understanding of the teaching? - ANS-"I will hire someone to
trim the tree that hangs low over the stairs of my front porch."
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia.
Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all
that apply.) - ANS-assist the client with a partial bed bath, measure the client's BP after the
nurse administers an antihypertensive medication, use a communication board to ask what the
client wants for lunch
A nurse is caring for a client who is expressing anger about the diagnosis of colorectal cancer.
Which of the following actions should the nurse take? - ANS-Reassure the client that this is an
expected response to grief.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of
the following types of dressing should the nurse use? - ANS-Hydrocolloid
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear. - ANS-Press
gently on the tragus of the client's ear.
, A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
Which of the following actions should the nurse take? - ANS-Subtract the amount of irrigant
used from the client's urine output.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client? - ANS-Make
sure the client wears a mask when outside her room if there is construction in the area.
A nurse is auscultating the anterior chest of a client who was newly admitted to a
medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the
stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the
clip.) - ANS-Normal breath sounds
A nurse is planning strategies to manage time effectively for client care. Which of the following
strategies should the nurse implement? - ANS-Use the planning step of the nursing process to
prioritize client care delivery.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the
use of thigh-length sequential compression sleeves. Which of the following actions should the
nurse take? - ANS-Make sure two fingers can fit under the sleeves.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques
should the nurse use when performing nasotracheal suctioning for the client? - ANS-Apply
intermittent suction when withdrawing the catheter.
A nurse is assessing a client who reports increased pain following physical therapy. Which of
the following questions should the nurse ask when assessing the quality of the client's pain? -
ANS-"Is your pain sharp or dull?"
A nurse is providing discharge teaching to a client about self-administering heparin. Which of
the following instruction should the nurse include in the teaching? - ANS-Administer the
medication into the abdomen.
A nurse is a long-term care facility is caring for a client who dies during the nurse's shift. Identify
the sequence in which the nurse should perform the following steps. (Move the steps into the
box on the right, placing them in the order of performance. Use all the steps.) - ANS-Obtain the
pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the
client's body. Ask the client's family members if they would like to view the body. Place a name
tag on the body.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home.
Which of the following instructions should the nurse include in teaching? - ANS-Use
tracheostomy covers when outdoors.
