ATI Fundamentals Final Exam
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1. a nurse is admitting a client who will undergo a craniotomy. During the
planning phase of the nursing process, which of the following actions should
the nurse take?
a) establish client outcomes
b) collect information about past health problems
c) determine whether the client has met specific goals
d) identify the client's specific health problem: a) establish client outcomes
The planning phase includes developing goals and outcomes that help the nurse
create the client's plan of care.
The nursing process:
step 1. assessment phase- collect information about past health problems (vitals,
age, height)
step 2. analysis phase- identify the client's specific health problem
step 3. planning phase- establish client goals and outcomes and selects interven-
tions that will help to achieve them. Also involves setting care priorities.
step 4. implementation- provides client care and uses interpersonal/technical skills
when implementing nursing interventions
step 5. evaluation phase- use critical thinking skills to determine whether the client
has met a specific goal. examines results, compares the data, identifies errors, and
considers pt's situation
2. a client who reports shortness of breath requests the nurse's help in chang-
ing positions. After repositioning the client, which of the following actions
should the nurse take next?
a) encourage the client to take deep breaths
b) observe the client's rate, depth, and character of respirations
c) prepare to administer oxygen
d) give the client a backrub to promote relaxation: b) observe the client's rate,
depth, and character of respirations
3. a nurse is collecting health history data from a client who is deaf and uses
American sign language(ASL) to communicate. The nurse will be working with
an ASL interpreter. Which of the following actions should the nurse take when
working with the interpreter?
a) face away from the client to avoid distractions
b) pace speech to allow time for the interpreter to convey the words
, ATI Fundamentals Final Exam
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c) make eye contact with the interpreter when explaining the procedure
d) stand in the background while the interpreter translates the message: b)
pace speech to allow time for the interpreter to convey the words
4. a nurse manager is providing teaching to a group of newly licensed nurses
about the ways that clients acquire healthcare-associated-infections (HAI's).
Which of the following routes of infection should the manager identify as an
iatrogenic HAI?
a) infection required from improper hand hygiene
b) infection acquired by drug resistance
c) infection acquired by inappropriate waste disposal
d) infection acquired from diagnostic procedure: d) infection acquired from
diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
5. a nurse is caring for a client who has Clostridium difficile infection and is
in contact isolation. Which of the following actions should the nurse take?
a) wear gloves when changing the clients gown
b) use alcohol-based sanitizers to cleanse the hands
c) wear a mask when assisting the client with his meal tray
d) place the client on a complete bed rest: a) wear gloves when changing the
clients gown
-alcohol-based sanitizers are ineffective against the spores of C.difficile
-nurse should wear a mask when working within 3 ft of a patient with droplet
precautions
-the nurse should not place the client on complete bed rest because this places him
at risk for the hazards of immobility, such as impaired skin integrity and retained
respiratory secretions. The nurse should instruct the patient to stay in his room but
to move, cough, and deep breathe at least every 2 hours
6. a nurse is reviewing the use of side rails with an A.P. Which of the following
statements by the A.P indicates that further teaching is required?
a) "I should not leave all 4 side rails up unless there is a prescription for
restraints"
b) "an alert client will be the safest if I raise the 2 upper side rails at the head
of the bed"
c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
, ATI Fundamentals Final Exam
Study online at https://quizlet.com/_bef6mr
d) "if a client is sedated, I should raise all 4 side rails to prevent a fall out of
bed": c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
7. which diseases have airborne precautions?: Varicella, TB, and measles
8. which diseases have contact precautions?: C.diff, MRSA, scabies, van-
comycin resistant enterococci
9. which diseases have droplet precautions?: rubella, influenza, meningoccal,
pneumonia, streptococcal pharyngitis
10. A nurse in a provider's office is measuring a client & notes a loss in
height from the previous year. The nurse should identify this finding as a
manifestation of which of the following musculoskeletal system disorders?
a) osteoporosis
b) scoliosis
c) kyphosis
d) lordosis: a) osteoporosis
A loss of height is often an early indication of osteoporosis with occurs due to a loss
of calcium in the vertebrae which can cause them to fracture and collapse.
- scoliosis does not precipitate a decrease in the height of the client. It is an abnormal
lateral curve of the sign
- kyphosis does not precipitate a decrease in the height of a client. It is an exagger-
ated posterior curvature of the thoracic spine hunchback
- lordosis does not precipitate a decrease in the height of a client. It is an exaggerated
lumbar curvature way back
11. Not on ATI:
The nurse is planning care for a pt with severe burns. Which of the following
is this pt at risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit: 1. intracellular fluid deficit
Because this pt was severely burned, the fluid within the cells is diminished, leading
to an intracellular fluid deficit.
12. Not on ATI:
, ATI Fundamentals Final Exam
Study online at https://quizlet.com/_bef6mr
The nurse is to obtain a stool specimen from a client who reported that he is
taking iron supplements. The nurse would expect the stool to be which color?
a) Black
b) Red
c) Dark brown
d) Green: Black
13. A nurse is obtaining a health history from the newly admitted client who
has chronic pain in the knee. What should the nurse include in the pain
assessment? Select all that apply.
1) Pain history, including location, intensity, and quality of pain
2) Client's purposeful body movement in arranging the papers on the bedside
table
3) Pain pattern, including precipitating and alleviating factors
4) Vital signs such as increased blood pressure and heart rate
5) The client's family statement about increases in pain with ambulation: 1)
Pain history, including location, intensity, and quality of pain
3) Pain pattern, including precipitating and alleviating factors
14. A nurse is obtaining a clients blood pressure in a client's lower extremity.
Which of the following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh: d) place
the bladder of the cuff over the posterior aspect of the thigh
This is the correct position for the bladder of the class when the nurse is measuring
a lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal artery
- the nurse should measure the blood pressure with the client prone is possible
otherwise the client should lie supine with knee flexed
- the nurse should position the cuff 2.5cm (1 in) above the popliteal artery
15. NOT ATI
The nurse is performing nasotracheal suctioning. After suctioning the client's
trachea for fifteen seconds, large amounts of thick yellow secretions return.
What action should the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
Study online at https://quizlet.com/_bef6mr
1. a nurse is admitting a client who will undergo a craniotomy. During the
planning phase of the nursing process, which of the following actions should
the nurse take?
a) establish client outcomes
b) collect information about past health problems
c) determine whether the client has met specific goals
d) identify the client's specific health problem: a) establish client outcomes
The planning phase includes developing goals and outcomes that help the nurse
create the client's plan of care.
The nursing process:
step 1. assessment phase- collect information about past health problems (vitals,
age, height)
step 2. analysis phase- identify the client's specific health problem
step 3. planning phase- establish client goals and outcomes and selects interven-
tions that will help to achieve them. Also involves setting care priorities.
step 4. implementation- provides client care and uses interpersonal/technical skills
when implementing nursing interventions
step 5. evaluation phase- use critical thinking skills to determine whether the client
has met a specific goal. examines results, compares the data, identifies errors, and
considers pt's situation
2. a client who reports shortness of breath requests the nurse's help in chang-
ing positions. After repositioning the client, which of the following actions
should the nurse take next?
a) encourage the client to take deep breaths
b) observe the client's rate, depth, and character of respirations
c) prepare to administer oxygen
d) give the client a backrub to promote relaxation: b) observe the client's rate,
depth, and character of respirations
3. a nurse is collecting health history data from a client who is deaf and uses
American sign language(ASL) to communicate. The nurse will be working with
an ASL interpreter. Which of the following actions should the nurse take when
working with the interpreter?
a) face away from the client to avoid distractions
b) pace speech to allow time for the interpreter to convey the words
, ATI Fundamentals Final Exam
Study online at https://quizlet.com/_bef6mr
c) make eye contact with the interpreter when explaining the procedure
d) stand in the background while the interpreter translates the message: b)
pace speech to allow time for the interpreter to convey the words
4. a nurse manager is providing teaching to a group of newly licensed nurses
about the ways that clients acquire healthcare-associated-infections (HAI's).
Which of the following routes of infection should the manager identify as an
iatrogenic HAI?
a) infection required from improper hand hygiene
b) infection acquired by drug resistance
c) infection acquired by inappropriate waste disposal
d) infection acquired from diagnostic procedure: d) infection acquired from
diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
5. a nurse is caring for a client who has Clostridium difficile infection and is
in contact isolation. Which of the following actions should the nurse take?
a) wear gloves when changing the clients gown
b) use alcohol-based sanitizers to cleanse the hands
c) wear a mask when assisting the client with his meal tray
d) place the client on a complete bed rest: a) wear gloves when changing the
clients gown
-alcohol-based sanitizers are ineffective against the spores of C.difficile
-nurse should wear a mask when working within 3 ft of a patient with droplet
precautions
-the nurse should not place the client on complete bed rest because this places him
at risk for the hazards of immobility, such as impaired skin integrity and retained
respiratory secretions. The nurse should instruct the patient to stay in his room but
to move, cough, and deep breathe at least every 2 hours
6. a nurse is reviewing the use of side rails with an A.P. Which of the following
statements by the A.P indicates that further teaching is required?
a) "I should not leave all 4 side rails up unless there is a prescription for
restraints"
b) "an alert client will be the safest if I raise the 2 upper side rails at the head
of the bed"
c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
, ATI Fundamentals Final Exam
Study online at https://quizlet.com/_bef6mr
d) "if a client is sedated, I should raise all 4 side rails to prevent a fall out of
bed": c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
7. which diseases have airborne precautions?: Varicella, TB, and measles
8. which diseases have contact precautions?: C.diff, MRSA, scabies, van-
comycin resistant enterococci
9. which diseases have droplet precautions?: rubella, influenza, meningoccal,
pneumonia, streptococcal pharyngitis
10. A nurse in a provider's office is measuring a client & notes a loss in
height from the previous year. The nurse should identify this finding as a
manifestation of which of the following musculoskeletal system disorders?
a) osteoporosis
b) scoliosis
c) kyphosis
d) lordosis: a) osteoporosis
A loss of height is often an early indication of osteoporosis with occurs due to a loss
of calcium in the vertebrae which can cause them to fracture and collapse.
- scoliosis does not precipitate a decrease in the height of the client. It is an abnormal
lateral curve of the sign
- kyphosis does not precipitate a decrease in the height of a client. It is an exagger-
ated posterior curvature of the thoracic spine hunchback
- lordosis does not precipitate a decrease in the height of a client. It is an exaggerated
lumbar curvature way back
11. Not on ATI:
The nurse is planning care for a pt with severe burns. Which of the following
is this pt at risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit: 1. intracellular fluid deficit
Because this pt was severely burned, the fluid within the cells is diminished, leading
to an intracellular fluid deficit.
12. Not on ATI:
, ATI Fundamentals Final Exam
Study online at https://quizlet.com/_bef6mr
The nurse is to obtain a stool specimen from a client who reported that he is
taking iron supplements. The nurse would expect the stool to be which color?
a) Black
b) Red
c) Dark brown
d) Green: Black
13. A nurse is obtaining a health history from the newly admitted client who
has chronic pain in the knee. What should the nurse include in the pain
assessment? Select all that apply.
1) Pain history, including location, intensity, and quality of pain
2) Client's purposeful body movement in arranging the papers on the bedside
table
3) Pain pattern, including precipitating and alleviating factors
4) Vital signs such as increased blood pressure and heart rate
5) The client's family statement about increases in pain with ambulation: 1)
Pain history, including location, intensity, and quality of pain
3) Pain pattern, including precipitating and alleviating factors
14. A nurse is obtaining a clients blood pressure in a client's lower extremity.
Which of the following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh: d) place
the bladder of the cuff over the posterior aspect of the thigh
This is the correct position for the bladder of the class when the nurse is measuring
a lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal artery
- the nurse should measure the blood pressure with the client prone is possible
otherwise the client should lie supine with knee flexed
- the nurse should position the cuff 2.5cm (1 in) above the popliteal artery
15. NOT ATI
The nurse is performing nasotracheal suctioning. After suctioning the client's
trachea for fifteen seconds, large amounts of thick yellow secretions return.
What action should the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
