Foundations of Nursing Exam 1 ATI Questions and Answers
A nurse is preparing to conduct an initial survey and assessment on a newly admitted
client. Which of the following actions should the nurse plan to take? - -Engage in active
listening with the client and allow the client to express concerns early in the assessment
process
-A nurse is conducting a general survey on a client and notes a continuous twitching
movement of a muscle in the client's left arm. Which of the following terms should the
nurse use to describe the involuntary movement? - -Fasciculation
-A nurse is documenting information in a client's medical record during an initial
assessment. Which of the following information should the nurse include in the
documentation? (Select all that apply) - -Use of assistive devices, height and weight,
behavior and mood
-A nurse is preparing to obtain a client's height during a general survey. Which of the
following actions should the nurse take? - -Ensure the client's feet are in contact with the
wall or measuring pole
-A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral
probe in their mouth. Which of the following alternative routes should the nurse use to
obtain the most accurate core temp of the client? - -Rectal
-A nurse is having difficulty obtaining a pulse ox reading from a client. The nurse should
identify which of the following factors can interfere with obtaining a pulse ox reading? - -
Recent scan with contrast dye
-A nurse is caring for a client who is reporting pain as a 4 on a scale 0-10. Upon further
assessment, which of the following findings should the nurse identify as manifestations of
chronic pain? (Select all that apply) - -The client reports that the pain has been present for
4 years, the client reports never feeling total relief from pain, the client reports that the
pain is recurring and does not always originate in the same location
-A nurse is planning to take an orthostatic bp from a client who has a syncope. In what
order should the nurse take the following steps? - -Place the client in a supine position and
allow them to rest, take the clients bp in the supine position, keep the cuff in place and
assist the client to a seated position, take the client's blood pressure in a seated position,
assist client to stand and obtain their bp
-A nurse is conducting a general survey on a client who is being admitted to a long-term
care facility. The nurse is assessing the client's emotional state. Which of the following
findings should the nurse record as a subjective, unexpected finding? - -The client reports
they feel sad and lonely most of the time
,-A nurse is documenting vital signs in the medical record following a general survey.
Which of the following entries should the nurse place in the record? - -Oxygen saturation
96% on O2 2L/min via nasal cannula
-A nurse is completing an initial assessment checklist on an older adult client. The client is
accompanied by their caregiver. For which of the following indicators should the nurse
observe when assessing for potential maltreatment of the client? (Select all that apply) - -
Dirty clothing, unexplained physical injuries, malnourished appearance
-A nurse assess a client's respiratory rate and notes that it is below the expected reference
range. The nurse should identify that which of the following findings can cause a decreased
respiratory range? - -The client takes a narcotic pain medication for chronic pain
-A nurse is providing teaching to a client who asks, "What are things that can affect my
blood pressure?" Which of the following information should the nurse include as factors
that affect bp? (Select all that apply) - -Time of day, obesity, diuretic medication, smoking
-A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110 bpm.
The nurse should identify this as which of the following unexpected findings? - -
Tachycardia
-A nurse is assessing a client's respirations and notes they are shallow and at a rate of
24/min. The nurse should identify this as which of the following unexpected findings? - -
Tachypnea
-A nurse is assessing a client's neck. Which of the following should the nurse ask the client
to perform during the assessment? - -Instruct the client to swallow, apply downward
pressure and ask the client to shrug their shoulders, request the client to move their head
forward and backward and then side to side
-A nurse is preparing to care for a group of clients in an acute care setting. Which of the
following assessments should the nurse plan to perform on every client? - -Lung sounds,
bowel sounds, pedal pulses, mental status
-A nurse is performing an assessment of a client's abdomen. Which of the following actions
should the nurse take? - -Auscultate bowel sounds prior to palpating
-A nurse is preparing an assessment on a client who reports ear pain. Which of the
following actions should the nurse take? - -Palpate the mastoid area for pain
-A nurse is assessing a client's posterior and lateral chest. Which of the following actions
should the nurse take? - -Observe for the use of accessory muscles during inspiration
-A nurse is assessing a client's vital signs. while counting the number of respirations.
Which of the following information should the nurse collect? - -Characteristics of the
respirations
, -A nurse is performing an assessment of a client's lower extremities. Which of the
following actions should the nurse include in this assessment? - -Inspect the pattern of hair
distribution
-A nurse is evaluating an older adult client for an alteration in orientation. Which of the
following questions should the nurse ask the client? - -Can you tell me what month it is?
-A nurse is assessing a client's radial pulse rate. Which of the following information should
the nurse collect while performing this action? - -Regularity of the pulse, strength of the
pulse
-A nurse is preparing to perform a head-to-toe assessment on a client. Which of the
following tools should the nurse plan to gather? - -Penlight, stethoscope,
sphygmomanometer
-A nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which
of the following should the nurse inspect when performing a general survey of the client? -
-Nutritional status, hygiene, posture
-A nurse is inspecting the anterior chest of a client. Which of the findings should the nurse
report to the provider? - -Distended veins in one breast
-A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient
setting. At which of the following times should the nurse plan to collect information about
the client's general appearance? - -During an interview about the client's health history,
when introducing themselves to the client, while collecting the client's vital signs
-A nurse is preparing to assess the status of a client's upper extremities. Which of the
following actions should the nurse take? - -Inspect the condition of each fingernail,
compare the amplitude of the radial pulses bilaterally, palpate the shoulder, elbow, wrist,
and finger joints
-A nurse is planning to complete a physical assessment on a client. Which of the following
actions should the nurse plan to include? - -Use quotation marks when documenting client
statements
-A nurse is teaching a client who has a new diagnosis of a skin infection about the function
of the skin in the body. Which of the following statements should the nurse include? - -"The
skin contains Langerhans cells that kill pathogens."
-A nurse is discussing health promotion programs with a client. Which of the following
information should the nurse include? - -Health promotion programs emphasize behavior
changes in relation to prevention of illness.
A nurse is preparing to conduct an initial survey and assessment on a newly admitted
client. Which of the following actions should the nurse plan to take? - -Engage in active
listening with the client and allow the client to express concerns early in the assessment
process
-A nurse is conducting a general survey on a client and notes a continuous twitching
movement of a muscle in the client's left arm. Which of the following terms should the
nurse use to describe the involuntary movement? - -Fasciculation
-A nurse is documenting information in a client's medical record during an initial
assessment. Which of the following information should the nurse include in the
documentation? (Select all that apply) - -Use of assistive devices, height and weight,
behavior and mood
-A nurse is preparing to obtain a client's height during a general survey. Which of the
following actions should the nurse take? - -Ensure the client's feet are in contact with the
wall or measuring pole
-A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral
probe in their mouth. Which of the following alternative routes should the nurse use to
obtain the most accurate core temp of the client? - -Rectal
-A nurse is having difficulty obtaining a pulse ox reading from a client. The nurse should
identify which of the following factors can interfere with obtaining a pulse ox reading? - -
Recent scan with contrast dye
-A nurse is caring for a client who is reporting pain as a 4 on a scale 0-10. Upon further
assessment, which of the following findings should the nurse identify as manifestations of
chronic pain? (Select all that apply) - -The client reports that the pain has been present for
4 years, the client reports never feeling total relief from pain, the client reports that the
pain is recurring and does not always originate in the same location
-A nurse is planning to take an orthostatic bp from a client who has a syncope. In what
order should the nurse take the following steps? - -Place the client in a supine position and
allow them to rest, take the clients bp in the supine position, keep the cuff in place and
assist the client to a seated position, take the client's blood pressure in a seated position,
assist client to stand and obtain their bp
-A nurse is conducting a general survey on a client who is being admitted to a long-term
care facility. The nurse is assessing the client's emotional state. Which of the following
findings should the nurse record as a subjective, unexpected finding? - -The client reports
they feel sad and lonely most of the time
,-A nurse is documenting vital signs in the medical record following a general survey.
Which of the following entries should the nurse place in the record? - -Oxygen saturation
96% on O2 2L/min via nasal cannula
-A nurse is completing an initial assessment checklist on an older adult client. The client is
accompanied by their caregiver. For which of the following indicators should the nurse
observe when assessing for potential maltreatment of the client? (Select all that apply) - -
Dirty clothing, unexplained physical injuries, malnourished appearance
-A nurse assess a client's respiratory rate and notes that it is below the expected reference
range. The nurse should identify that which of the following findings can cause a decreased
respiratory range? - -The client takes a narcotic pain medication for chronic pain
-A nurse is providing teaching to a client who asks, "What are things that can affect my
blood pressure?" Which of the following information should the nurse include as factors
that affect bp? (Select all that apply) - -Time of day, obesity, diuretic medication, smoking
-A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110 bpm.
The nurse should identify this as which of the following unexpected findings? - -
Tachycardia
-A nurse is assessing a client's respirations and notes they are shallow and at a rate of
24/min. The nurse should identify this as which of the following unexpected findings? - -
Tachypnea
-A nurse is assessing a client's neck. Which of the following should the nurse ask the client
to perform during the assessment? - -Instruct the client to swallow, apply downward
pressure and ask the client to shrug their shoulders, request the client to move their head
forward and backward and then side to side
-A nurse is preparing to care for a group of clients in an acute care setting. Which of the
following assessments should the nurse plan to perform on every client? - -Lung sounds,
bowel sounds, pedal pulses, mental status
-A nurse is performing an assessment of a client's abdomen. Which of the following actions
should the nurse take? - -Auscultate bowel sounds prior to palpating
-A nurse is preparing an assessment on a client who reports ear pain. Which of the
following actions should the nurse take? - -Palpate the mastoid area for pain
-A nurse is assessing a client's posterior and lateral chest. Which of the following actions
should the nurse take? - -Observe for the use of accessory muscles during inspiration
-A nurse is assessing a client's vital signs. while counting the number of respirations.
Which of the following information should the nurse collect? - -Characteristics of the
respirations
, -A nurse is performing an assessment of a client's lower extremities. Which of the
following actions should the nurse include in this assessment? - -Inspect the pattern of hair
distribution
-A nurse is evaluating an older adult client for an alteration in orientation. Which of the
following questions should the nurse ask the client? - -Can you tell me what month it is?
-A nurse is assessing a client's radial pulse rate. Which of the following information should
the nurse collect while performing this action? - -Regularity of the pulse, strength of the
pulse
-A nurse is preparing to perform a head-to-toe assessment on a client. Which of the
following tools should the nurse plan to gather? - -Penlight, stethoscope,
sphygmomanometer
-A nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which
of the following should the nurse inspect when performing a general survey of the client? -
-Nutritional status, hygiene, posture
-A nurse is inspecting the anterior chest of a client. Which of the findings should the nurse
report to the provider? - -Distended veins in one breast
-A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient
setting. At which of the following times should the nurse plan to collect information about
the client's general appearance? - -During an interview about the client's health history,
when introducing themselves to the client, while collecting the client's vital signs
-A nurse is preparing to assess the status of a client's upper extremities. Which of the
following actions should the nurse take? - -Inspect the condition of each fingernail,
compare the amplitude of the radial pulses bilaterally, palpate the shoulder, elbow, wrist,
and finger joints
-A nurse is planning to complete a physical assessment on a client. Which of the following
actions should the nurse plan to include? - -Use quotation marks when documenting client
statements
-A nurse is teaching a client who has a new diagnosis of a skin infection about the function
of the skin in the body. Which of the following statements should the nurse include? - -"The
skin contains Langerhans cells that kill pathogens."
-A nurse is discussing health promotion programs with a client. Which of the following
information should the nurse include? - -Health promotion programs emphasize behavior
changes in relation to prevention of illness.
