ATI FUNDAMENTALS PROCTORED RETAKE EXAM 2 VERSIONS EACH
WITH 70 QUESTIONS AND NGN QUESTIONS 2019 GRADED A+/UPDATED
A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate
to an assistive personnel?
A. Changing the dressing for a client who has a stage 3 pressure injury
B. Determining a client's response to a diuretic
C. Comparing radial pulses for a client who is postoperative
D. Providing postmortem care to a client
Answer: D. Providing postmortem care to a client
Postmortem care serves several purposes, including: preparing the patient for viewing by family.
ensuring proper identification of the patient prior to transportation to the morgue or funeral home.
providing appropriate disposition of patient's belongings. maintaining vital organs, if donation is
planned.)
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the
following statements by the client indicates an understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms
Answer: C. I use ginger when I get car sick
A nurse is caring for a client who has influenza and isolation precautions in place. Which of the
following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room.
Answer: A. Wear a mask when working within 3 feet of the client
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube.
Which of the following actions should the nurse take?
A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C. Allow room for two fingers to fit between the clients skin and the restraints
D. Remove the restraints every 4 hr.
Answer: C. Allow room for two fingers to fit between the clients skin and the restraints
A nurse is admitting a client who has tuberculosis. Which of the following types of transmission
precautions should the nurse plan to initiate?
A. Droplet
B. Airbornes
C. Protective environment
D. Contact
Answer: B. Airbornes
A nurse in a well-child clinic receives a telephone call from a parent who states that their child
accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses
should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac.
Answer: A. Have your child drink one large glass of water.
A nurse is documenting a client's medical record. Which of the following entries should the nurse
record.
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
D. Drank adequate amounts of fluid with meals.
Answer: B. Administered pain medication
A nurse is providing oral care for a client who is unconscious. Which of the following actions should
the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client’s lips
D. Rinse the client’s mouth with an alcohol-based mouthwash
Answer: A. Place the client in a side-lying position.
A nurse is collaborating with a risk management team about potential legal issues involving client care.
The nurse should identify which of the following situations is an example of negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility.
Answer: C. A nurse begins a blood transfusion without obtaining consent.
A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which
of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D Collect 1 ml of sputum.
Answer: B. Offer the client oral hygiene after the collection
A nurse is assessing an older client. Which of the following findings should the nurse expect?
A. Decreased sense of balanced
B. Increased nighttime sleeping
C. Heightened sense of pain
D. Nighttime urinary incontinence
Answer: A. Decreased sense of balanced
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which
of the following instructions should the nurse include in the teaching?
(select all that apply)
A. “Cut the opening of the pouch ⅛ of an inch larger than the stoma”
B. “Place a piece a gauze over the stoma while changing the pouch”
C. “Use povidone-iodine to clean around the stoma”
D. “Empty the ostomy pouch when it becomes one-third full of contents”
E. “Expect the stoma to turn a purple-blue color as its heals”
Answer: A. “Cut the opening of the pouch ⅛ of an inch larger than the stoma “
B. “Place a piece a gauze over the stoma while changing the pouch”
C. “Use povidone-iodine to clean around the stoma”
D. “Empty the ostomy pouch when it becomes one-third full of contents”
A nurse is preparing to obtain informed consent from a client who speaks a different language than the
nurse. Which of the following actions should the nurse take?
A. “Request that an assistive personnel interpret the information for the client”
B. “Use proper medical terms when giving information to the client”
C. “Offer written information in the client’s language”
D. “Avoid using gestures when speaking to the client”
Answer: C. “Offer written information in the client’s language”
A nurse is teaching a client about home care equipment. Which of the following information should the
nurse include in the teaching? (select all that apply)
A. “Avoid using wool blankets when receiving oxygen”
B. “Keep the oxygen delivery system 0.6 m (2 feet) from any heat source”
C. “Check the oxygen delivery rate at least once a day”
D. “Align the middle of the ball in the flow meter with the line of the prescribed flow rate”
E. “Lay the oxygen tank flat when storing”
Answer: A. “Avoid using wool blankets when receiving oxygen”
C. “Check the oxygen delivery rate at least once a day”
D. “Align the middle of the ball in the flow meter with the line of the prescribed flow rate”
A nurse is planning care for a client who reports insomnia. Which of the following actions should the
nurse perform shortly before bedtime?
A. Provide a late supper.
B. Offer a wet washcloth for the client to wash her face
C. Perform range-of-motion exercises
D. Prepare hot cocoa or tea for the client
Answer: A. Provide a late supper.
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the
following clients should the nurse see first?
A. A client who has acute abdominal pain of 4 on a scale from 0 to 10
B. A client who has pneumonia and an oxygen saturation of 96%
C. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
D. A client who has a urinary tract infection and low-grade fever
Answer: C. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
A nurse is reviewing a client’s intake and output and notes the following: 0.9% sodium chloride 600mL
IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis,
40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client’s
net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero
if it applies. Do not use a trailing zero.)
Answer: 700 mL, the rest are output
A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include
that which if the following requires the completion of an incident report?
A. A client’s prescribed laboratory testing was not obtained
B. A client withdrew consent for a procedure
C. An oncoming nurse arrived to work late
D. A nurse transfused a unit of packed RBCs in 2 hr.
Answer: A. A client’s prescribed laboratory testing was not obtained
A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic
wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse
consult to learn more about the intervention.
A. The client’s plan of care
B. The nurse practice act
C. The material safety data sheet
D. The policy and procedure manual
Answer: D. The policy and procedure manual
A nurse is performing postural drainage with percussion and vibration for a client who has cystic
fibrosis. Which of the following actions should the nurse take?
A. Cover the area of percussion with a towel.
B. Instruct the client to exhale quickly during vibration
C. Schedule postural drainage after meals
D. Perform percussion over the lower back
Answer: D. Perform percussion over the lower back
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has
difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the
following images indicates the correct number of mL the nurse should administer? (round answer to the
nearest whole number.)
Answer: Should be the first syringe 8ml
A nurse is admitting a client who is malnourished. The client states, “My wedding ring is loose and I'm
worried I will lose it if it falls off. “Which of the following is an appropriate response by the nurse?
A. “I will place it in your drawer so it won’t get lost.”
B. “I can pin it to your hospital gown so you won’t lose it.”
C. “I will hold onto it until a family member can take it home.”
D. “I can put it in a locked storage unit for you.”
Answer: D. “I can put it in a locked storage unit for you.”
A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the
following clinical situations should the nurse apply restraints?
A. If the client is pacing in the hallway
B. As a part of a fall prevention program
C. At the request of the client’s family
D. When the client poses a threat to self
Answer: D. When the client poses a threat to self
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a
straight catheterization on a client. In which of the following roles is the nurse manager functioning?
A. Case manager
B. Client educator
C. Client care provider
D. Client advocate
Answer: D. Client advocate
A charge nurse in a long-term care facility is preparing an educational program about delirium for
newly hired nurses. Which of the following statements should the nurse plan to include?
A. “Delirium does not affect a client’s perception of her environment.”
B. “Delirium does not affect a client’s sleep cycle.”
C. “Delirium has an abrupt onset.”
D. “Delirium has a slow progression.”
Answer: C. “Delirium has an abrupt onset.”
A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client
states, “The doctor must be wrong. I can't be that sick”. The nurse should inform the client that their
reaction is an example of which of the following expected responses to grief?
A. Acceptance
B. Denial
C. Anger
D. Depression
Answer: B. Denial
A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of
the following situations as an ethical dilemma?
A. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility
for her actions
B. A client who has Crohn’s disease reports that his prescription drug plan will not pay for his
medications.
C. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she
“doesn't like him.”
D. The family of a client who has a terminal illness asks that the provider not tell the client the
diagnosis
Answer: D. The family of a client who has a terminal illness asks that the provider not tell the client the
diagnosis
A nurse is teaching a client about performing breast self-examinations. Which of the following
statements by the clients indicates an understanding of the teaching?
A. “I should perform my self-exam the week that my period starts”
B. “I should make different patterns on each breast when I do my self-exam.”
C. “I should use the palm of my hand to apply pressure to each breast.”
D. “I should make circular motions with my fingertips under my arms.”
Answer: D. “I should make circular motions with my fingertips under my arms.”
A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which
of the following actions should the nurse take?
A. Keep his knees straight when moving the client
B. Position the chair next to the bed as a 90 degree angle
C. Stand with his feet together when lifting the client
D. Have the client bear weight on her stronger leg
Answer: D. Have the client bear weight on her stronger leg
A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for
ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify the sequence of steps the
nurse should follow to administer the medication. ( Move the steps into the box on the right, placing
them in the order of performance. Use all the steps.)
A. Perform hand hygiene.
B. Select the injection port of the IV tubing closest to the client.
C. Cleanse the injection port with an antiseptic swab.
D. Aspirate for blood return. Inject the medication.
Answer: A. Perform hand hygiene.
B. Select the injection port of the IV tubing closest to the client.
C. Cleanse the injection port with an antiseptic swab.
D. Aspirate for blood return. Inject the medication.
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of
the following statements but the client indicates an understanding of the teaching
A. I should wait 3 minutes after mixing the insulin to inject it
B. I should draw up the NPH insulin before regular insulin
C. I should inject air into the vial of regular insulin first
D. I should roll the vial of NPH insulin between my hands before drawing it up
Answer: D. I should roll the vial of NPH insulin between my hands before drawing it up
A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which
of the following actions should the nurse take? (Select all that apply)
A. Slide the probe across the clients forehead
B. Pull the clients pinna up & back
C. Hold the client’s hair aside while performing the procedure
D. Document the client's temperature with “AX” next to the value
E. Move the probe in a circular motion
Answer: A. Slide the probe across the clients forehead
C. Hold the client’s hair aside while performing the procedure
A nurse is preparing to insert a peripheral IV catheter into the client’s arm. Which of the following
actions should the nurse take to help dilate the vein?
A. Stroke the skin near the vein in an upward position
B. Dangle the client’s arm over the edge of the bed
C. Apply a cool compress to the vein for 10 min
D. Instruct the client to flex their arm with the hand open
Answer: B. Dangle the client’s arm over the edge of the bed
A nurse is preparing to suction a client’s tracheostomy tube. Which of the following actions should the
nurse plan to take?
A. Apple intermittent suction during catheter insertion
B. Suction the client’s airway for 20 seconds with each pass
C. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning
D. Decrease suction pressure to 150 mm Hg if the oxygen saturation level drop during suctioning
Answer: D. Decrease suction pressure to 150 mm Hg if the oxygen saturation level drop during
suctioning
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the
following finding is the nurse’s priority?
A. Last bowel movement was 3 days ago
B. Reports pain of 8 on a scale of 0 to 10
C. Distended bladder
D. Respiratory rate 7/min
Answer: D. Respiratory rate 7/min
A nurse is caring for a client who has been treated multiple times for STIs. Which of the following
responses should the nurse take?
A. “You must have too many sexual partners”
B. “Why do you keep letting this happen?”
C. “Let's explore why this might be reoccuring”
D. “Don’t you have access to condoms?”
Answer: C. “Let's explore why this might be reoccuring”
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins
to experience a seizure. Which of the following actions should the nurse take first?
A. Move items in the room away from the client
B. Turn the client onto their side
C. Help the client lie on the floor
D. Loosen the client’s clothing
Answer: C. Help the client lie on the floor
A nurse is testing a client for conduction deafness by performing Weber’s test. Which of the following
actions should the nurse take when performing this test?
A. Move a vibrating tuning form in front of the client’s ear canals one after the other
B. Place the base of a vibrating tuning fork on the client’s mastoid process
C. Place the base of a vibrating tuning fork on the top of the client’s head
D. Count how many seconds a client can hear a tuning fork after it has been struck
Answer: C. Place the base of a vibrating tuning fork on the top of the client’s head
A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse
should identify which of the following medications can interact adversely with this supplement?
A. Warfarin
B. Albuterol
C. Levothyroxine
D. Atorvastatin
Answer: A. Warfarin
A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, “I
don’t want to go through with the procedure.” Which of the following actions should the nurse take?
A. Discuss alternative treatments with the client
B. Explain to the client the risks involved with not having the procedure
C. Express approval of the client’s decision to not have the procedure
D. Document the client’s decision in the medical record
Answer: D. Document the client’s decision in the medical record
A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the
following statements by the client indicates an understanding of the teaching?
A. “I will have my partner help me change position every 4 hours”
B. “I will remove my antiembolic stockings while I am in bed”
C. “I will hold my breath when rising from a sitting position”
D. “I will perform ankle and knee exercises every hour.”
Answer: D. “I will perform ankle and knee exercises every hour.”
A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full
to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid
diet?
A. Oatmeal
B. Applesauce
C. Scrambled eggs
D. Plain Yogurt
Answer: D. Plain Yogurt
A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions
should the nurse ask when assessing the client’s psychosocial history?
A. “What medications are you currently taking?”
B. “Are you experiencing any Pain?”
C. “Have any of your relatives been diagnosed with cancer?”
D. “What Techniques do you use to cope with stress?”
Answer: D. “What Techniques do you use to cope with stress?”
A nurse is performing a skin assessment on an older adult client. Which of the following findings
should the nurse expect?
A. Thickened outer layer of skin
B. Increased skin elasticity
C. Reduced sweat production
D. Increased Production of oils
Answer: C. Reduced sweat production
A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the
following responses should the nurse make?
A. “I would get a second opinion if I were you.”
B. “it might seem bad now, but things will get better.”
C. “it must be difficult for you to receive this kind of news.”
D. I think you would benefit from speaking with our chaplain.”
Answer: C. “it must be difficult for you to receive this kind of news.”
A nurse is preparing to obtain a health history from a client. Which of the following actions should the
nurse take?
A. Use the client’s first name when initially meeting the client.
B. Tell the client the purpose for collecting the information.
C. Explain to the client the necessity of full disclosure of information. ·
D. Avoid documenting direct quotes from the client as part of subjective data.
Answer: B. Tell the client the purpose for collecting the information.
A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s son
tells the nurse, “I don’t know what to tell my dad if he asks how he is going to die.” Which of the
following is an appropriate response by the nurse?
A. “Let’s talk more about your dad’s condition.”
B. “The social worker will help you answer those questions.”
C. “Try to help your dad enjoy this time as much as he can.”
D. “I think that you should discuss this with the hospice nurse.”
Answer: A. “Let’s talk more about your dad’s condition.”
A Nurse is preparing to administer several medications to a client. Which of the following data should
the nurse plan to use to confirm the client’s identity?
A. The client’s room number
B. The client’s admitting diagnosis
C. The name of the client’s next of kin
D. The client’s telephone number
Answer: D. The client’s telephone number
A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not
have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify
which of the following members of the health care team.
A. Social worker
B. Occupational therapist
C. Registered Dietician
D. Primary care provider
Answer: A. Social worker
A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin- resistant
Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse
indicates an understanding of the teaching?
A. “I will place the client in a Private room.”
B. “I will remove my gown before my gloves after providing client care.”
C. “I will wear an N95 respirator mask when caring for the client.”
D. “I will tell the client’s visitors to wear a mask when they are within 3 feet of the client.”
Answer: A. “I will place the client in a Private room.”
A nurse is planning care for a client who reports having a latex allergy. Which of the following
interventions should the nurse include in the plan?
A. Cover the blood pressure cuff with a stockinette.
B. Wear powdered gloves when providing care to the client.
C. Apply adhesive tape when securing an IV insertion site.
D. Use plastic syringes for medication administration.
Answer: A. Cover the blood pressure cuff with a stockinette.
A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client’s
signature, the client states, “I trust my doctor, but I don’t understand what is meant by resecting my
intestines.” Which of the following actions should the nurse take?
A. Describe the surgery to the client.
B. Notify the Provider.
C. Complete an incident report
D. Provide brochures about the procedure.
Answer: B. Notify the Provider.
A nurse is documenting client care. Which of the following abbreviations should the nurse use?
A. “SQ” for subcutaneous
B. “SS” for sliding scale
C. “BRP” for bathroom privileges
D.“OJ” for orange juice
Answer: C. “BRP” for bathroom privileges
A nurse is preparing to bathe a client who has dementia. Which of the following actions should the
nurse take?
A. Give detailed instructions for the client to follow.
B. Complete the bath even if the client is in distress.
C. Use distractions when bathing the client.
D. Allow the client to select the temperature of the bath water.
Answer: C. Use distractions when bathing the client.
A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions
should the nurse include to promote the client’s dignity?
A. Provide guided imagery exercises to the client.
B. Refrain from discussing the client’s prognosis
C. Suggest that the client keep a journal.
D. Encourage the client to share their life story.
Answer: B. Refrain from discussing the client’s prognosis
A nurse is caring for a client who has a closed wound drainage system. Which of the following actions
should the nurse take?
A. Wear sterile gloves when emptying the container.
B. Reset the container with the drainage port closed
C. Connect the drain to high pressure suction.
D. Press straight down on the container to create vacuum.
Answer: D. Press straight down on the container to create vacuum.
A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which
of the following responses should the nurse make?
A. “Will you please spell the name of that medication for me?”
B. “Let me clarify that you want the medication given qid, correct?”
C. “I will sign my name now and leave a space for you to sign your name.”
D. “Let me provide you with the client’s medical record number for identification.”
Answer: A. “Will you please spell the name of that medication for me?”
During change of shift report, a nurse discovers she overlooked a prescription for a type and crossmatch of a client who is to have surgery the next day. Which of the following actions should the nurse
take first?
A. Inform the provider of the delay in obtaining the type and cross-match.
B. Obtain the client’s type and cross-match.
C. Prepare an incident report for risk management.
D. Document the incident in the client’s medical record.
Answer: A. Inform the provider of the delay in obtaining the type and cross-match.
A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following
should be discarded in a biohazard bag?
A. An emesis basin filled with blood from severe coughing
B. A bedpan containing diarrhea from a client who was receiving antibiotics
C. A disposable tissue containing expectorated sputum
D. A calibrated toilet insert filled with urine.
Answer: A. An emesis basin filled with blood from severe coughing
A nurse is caring for a client who is receiving enteral feedings via NG tube.
Which following actions should the nurse take prior to administering the formula?
A. Check for gastric residual volume
B. Encourage the client to breathe deeply and cough.
C. Flush the tube with sterile 0.9% sodium chloride irrigation.
D. Encourage the client to take sips of water.
Answer: A. Check for gastric residual volume
A nurse is caring for a client immediately following the insertion of an NG tube. Which of the
following indingd should indicate to the nurse that the tube is placed incorrectly?
A. The client has a dry mouth
B. The client is coughing
C. The client has active bowel sounds
D. The client is hiccupping
Answer: B. The client is coughing
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following
actions should the nurse take to verify proper placement of the tube?
A. Assess the client for a gag reflex
B. Measure the pH of the gastric
C. Place the end of the NG tube in the water to observe for bubbling
D. Asculatate 2.5 cm above the umbilicus while injecting 15 ml of water
Answer: B. Measure the pH of the gastric
A nurse is caring for a client who reports a ptain level of 5 on a scale from 0-10. The client informs the
nurse that pain meds are not an option for managing pain. Which of the following is an appropriate
response by the nurse?
A. Would you like to get you a back massage?
B. Why do you think pain med is not going to help you?
C. You may take any herbal remedies you bring from home
D. I’m sure it will work if you just give it a chance
Answer: A. Would you like to get you a back massage?
A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following
findings should the nurse expect?
A. Bradycardia
B. Postural hypotension
C. Distended neck vein
D. Dependent edema
Answer: B. Postural hypotension
A nurse is caring for a client who is immunocompromised which of the following actions should the
nurse take?
A. Use sterile gloves to provide perineal care
B. Cleanse hands with an alcohol based hand rub before client contact
C. Have the client apply a mask when children are visiting
D. Place the client in a semi-private room
Answer: B. Cleanse hands with an alcohol based hand rub before client contact
A nurse is preparing to insert an iv catheter for a client following a right mastectomy.
Which of the following veins should the nurse select when initiating iv therapy?
A. The radial vein on the left arm
B. The cephalic vein in the left distal forearm
C. The cephalic within on the back of the right hand
D. The basilic vein in the right antecubital fossa
Answer: B. The cephalic vein in the left distal forearm
A nurse is caring for a client who has urinary incontinence. Which of the following interventions should
the nurse take to prevent skin breakdown?
A. Apply powder to the client perineal area
B. Restrict client's fluid intake
C. Request a prescriptions for an indwelling urinary catheter
D. Apply a moisture barrier ointment after perineal hygiene
Answer: D. Apply a moisture barrier ointment after perineal hygiene
A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the
nurse” I am looking forward to seeing my grandchildren grow up.” the nurse should identify the client
is experiencing which of the following stages of grief?
A. Acceptance
B. Bargaining
C. Anger
D. Denial
Answer: D. Denial
A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions
should the nurse include in the teaching?
A. Clean the hearing aid by soaking it in warm water
B. Turn the hearing aid off and the volume down before insertion
C. Replace the battery if the hearing aid emits a whistling sound
D. Leave the battery in place when the hearing aid is not in use
Answer: B. Turn the hearing aid off and the volume down before insertion
A nurse is assessing a client’s eyes for accommodation. Which of the following actions should the nurse
take?
A. Observe the client’s eyes for the six cardinal position of gaze
B. Verify the client's ability to read letters on a snellen eye chart
C. Check the client’s pupil reaction when focusing on distant and nearby objects
D. Test the client’s eyes for reactions to light response
Answer: C. Check the client’s pupil reaction when focusing on distant and nearby objects
A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the
following actions by the AP demonstrate an understanding of the teaching?
Answer: The AP keeps the object he is lifting close to his body
The question was worded differently but “holding the object close to body” is a correct answer for one
question.
A nurse is assessing a client who is immobile and notices a red area over the client’s coccyx. Which of
the following actions should the nurse take?
A. Change the clients position every 4 hours
B. Apply petroleum base ointment in the red area
C. Assess the red area for blanching
D. Use friction when cleansing the client’s skin
Answer: C. Assess the red area for blanching
same thing for this question, wording is different, but an answer is “assess for blanching.”
A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary
incontinence. Which of the following actions should the nurse include in the plan of care.
Answer: request a prescription for an indwelling urinary catheter
A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the
following information should be included in the teaching? (select all that apply)
A. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation
B. Remove from the artificial eye by retracting the upper eyelid
C. Apply pressure just below artificial eye to break the suction
D. Clear the artificial eye with hydrogen peroxide before storing
E. Retract the upper and lower lids to reinsert the artificial eye
Answer: C. Apply pressure just below artificial eye to break the suction
D. Clear the artificial eye with hydrogen peroxide before storing
E. Retract the upper and lower lids to reinsert the artificial eye
A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden
severe abdominal pain. Which of the following actions should the nurse take first?
A. Determine areas of resonance across the abdomen using a systematic approach
B. Expose the client’s abdomen to look for changes in appearance
C. Perform abdominal palpation by pressing gently with the finger pads
D. Use the diaphragm of the stethoscope to listen for bowel sounds
Answer: B. Expose the client’s abdomen to look for changes in appearance
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following
interventions is the nurses priority?
A. Determine the client’s reading ability
B. Review the use of an artificial larynx
C. With the client schedule a support session
D. For the client explain the techniques of esophageal speech
Answer: D. For the client explain the techniques of esophageal speech
A home care nurse is teaching a client about home safety. Which of the following statements by the
client indicates an understanding of the teaching? (select all that apply)
A. I will use the bars when getting in and out of the bath tub
B. I need to check my medications for expiration dates
C. I need to have a fire escape plan with my family
D. I will apply tape over frayed areas of electrical cords
E. I need to set my hot water heater to 140 degrees Fahrenheit
Answer: A. I will use the bars when getting in and out of the bath tub
B. I need to check my medications for expiration dates
C. I need to have a fire escape plan with my family
A nurse in an emergency department is assessing a client who reports a right lower quadrant pain,
nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?
A. Offer pain medication
B. Palpate the abdomen
C. Auscultate bowel sounds
D. Administer an antiemetic
Answer: C. Auscultate bowel sounds
A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the
following statement by the client partner indicates maladaptive coping?
Answer: I don't know of if I will be able to meet his physical needs.
A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should
anticipate application of which of the following dressings?
A. Dry gauge
B. Transparent
C. Calcium alginate
D. Hydrogel
Answer: B. Transparent
A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns
and calluses toes. Which of the following statements by the client indicates understanding of the
teaching?
A. I can apply lotion to soften the calluses as long as I don’t put lotion between my toes
B. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly
C. I should soak my feet in warm water daily to soften corns and calluses
D. should use an over the counter liquid medication to remove corns
Answer: A. I can apply lotion to soften the calluses as long as I don’t put lotion between my toes
A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the
following actions should the nurse take?
A. Tie the restraints to the side rail
B. Secure restraints with a square
C. knot Remove one restraint at a time
D. Remove the restraints every 3 hours
Answer: knot Remove one restraint at a time
A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions
should the nurse take? Select all that apply
A. Use an N95 respirator while providing client care
B. Wear a gown and gloves when providing client care
C. Assign the client to a private room with positive air flow
D. Wash hands with soap and water after contact with the client
E. Ensure the client does not receive fresh fruits
Answer: B. Wear a gown and gloves when providing client care
C. Assign the client to a private room with positive air flow
D. Wash hands with soap and water after contact with the client
A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the
following actions is appropriate to include in the clients plan of care?
A. Schedule the client as the first surgical procedure of the day
B. Cleanse the stoppers with primidone iodine for withdrawing medication
C. Remove the stop stocks from iv tubing
D. Ensure the gloves in the surgical suite are powdered gloves
Answer: A. Schedule the client as the first surgical procedure of the day
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse.
Which of the following action should the nurse take?
Answer: Direct verbal discharge instruction to the interpreter.
A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the
following factors is most likely to increase the clients motivation to learn?
A. The client’s belief that his needs will be met through education
B. The nurse explaining the need for education to the client
C. The client seeking family approval by agreeing to a teaching plan
D. The nurse’s empathy about the client having to self-inject
Answer: A. The client’s belief that his needs will be met through education
A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes.
Which of the following actions should the nurse take?
A. Heat the formula to 105 degrees Fahrenheit
B. Flush the tubing with 10 ml of water every 2 hours
C. Change the tubing every 72 hours
D. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)
Answer: D. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)
A nurse is teaching a client who requires maximum support about how to use a two wheeled walker.
Which of the following actions by the client indicates an understanding of teaching?
A. The client picks up the walker with each step
B. The client stoops slightly forward when moving the walker
C. The client stands with her elbows slightly flexed while holding the walker
D. The client moves the walker ahead 10 inches with each step (Incorrect b/c 6 inches max)
Answer: C. The client stands with her elbows slightly flexed while holding the walker
A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse
over hears the assistive personnel tell the client that if she does not remain in bed, he will place her in
restraints. The nurse should identify that the AP is committing which of the following torts?
A. Libel
B. Defamation of character
C. Assault
D. Battery
Answer: C. Assault
A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the
following actions should the nurse take?
A. Stabilize the vein by applying traction above the insertion site
B. Engorge the vein by placing the arm in the dependent position
C. Use friction at the insertion site to increase venous distention
D. Leave the tourniquet on for 30 to 60 seconds after initial insertion
Answer: B. Engorge the vein by placing the arm in the dependent position
A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose
and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
A. Prepare the client for a central venous line
B. Change the PN infusion bag every 48 hours
C. Administer the PN and fat emulsion separately
D. Obtain a random blood glucose daily
Answer: A. Prepare the client for a central venous line
A nurse is caring for a client who is schedule for surgery while witnessing the client signature. While
the client is saying I trust my doctor, but I don’t understand what he meant when he said he’ll reset my
intestines. Which of the following actions should the nurse take?
A. Provide brochures about the procedure
B. Notify the provider
C. Complete an incident report
D. Describe the surgery to the client
Answer: B. Notify the provider
A nurse is caring for a client who is agitated and threating to harm others. The nurse places the client in
restraints but does not notify the provider or obtain a prescription for the restraints. The situation
respects which of the following torts?
A. False imprisonment
B. Invasion of privacy Assault
C. Negligence
Answer: A. False imprisonment
A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the
nurse to take?
Answer: Place an activated tuning fork in the middle of the client’s forehead (should just be head not
forehead technically)
A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the
nurse wear a face shield.
Answer: Changing the brief of an older client who has Clostridium difficile
An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the
following interventions should the nurse suggest?
A. Use the television to mask external noises
B. Listen to soft music before lying down
C. Exercise just prior to bedtime (…ATI Ebook says excersice has to be at least 2 hours prior to
bedtime)
D. Keep the sleeping environment warm
Answer: B. Listen to soft music before lying down
A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she
wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her
provider. Which of the following is an appropriate response by the nurse?
Answer: You should ask the provider if she recommend traditional Chinese medicine.
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is
appropriate for the nurse to recommend?
A. Eat a light carbohydrate snack before bedtime
B. Exercise 1 hour before bedtime
C. Drink a cup of hot cocoa before bedtime
D. Take a 30 min nap daily
Answer: A. Eat a light carbohydrate snack before bedtime
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following
responses by a newly licensed nurse indicates understanding in the teaching?
A. Each element has a range 1 to 5 points
B. The higher the score the higher the pressure ulcer risk
C. The clients age is part of the measurement
D. The scale measures six elements
Answer: D. The scale measures six elements
A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the
following actions is appropriate for the nurse to include?
A. Ensure the client is free of metal objects
B. Administer 240 ml (8oz) oral contrast before the procedure (…wrong b/c IV contrast, not oral)
C. Monitor the client for pain in the suprapubic region
D. Assist the client with a bowel cleansing
Answer: A. Ensure the client is free of metal objects
A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who
are confused. Which of the following instructions should the staff nurse include”
Answer: I don't know of if I will be able to meet his physical needs.
A nurse is planning to obtain a blood sample from a client for capillary blood glucose post-test. Which
of the following should the nurse take to obtain the sample?
A. The pad of the finger tip
B. The lateral aspect of the finger
C. The pinna of the ear
D. The side of the wrist
Answer: B. The lateral aspect of the finger
.
A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of
the following actions should the nurse plan to complete first?
A. Provide the client with a contact number for a diabetes education specialist
B. Make a copy of the medication record of the reconciliation for the client
C. Determine whether the client can afford the insulin administration supplies
D. Obtain printed information about self-administration
Answer: C. Determine whether the client can afford the insulin administration supplies
A nurse is caring for a client who has influenza and isolation precautions in place. Which of the
following actions should the nurse take to prevent the spread of infection?
Answer: Wear a mask when working within 3feet of the client
A nurse is delegating client’s care to the assistive personnel. Which of the following tasks should the
nurse delegate to the AP?
Answer: ADLs (bathing, grooming, toileting, ambulate etc.) specimen collection, I&O, vital signs if
stable
A nurse is teaching about home safety with. Which of the following instructions should the nurse
include?
A. Use electrical tape to secure extension cords next to base boards on the floor
B. Replace carpet floors with tiles
C. Unplug electronics by grasping the cord
D. To use a fire extinguisher, aim high at the top of the flames
Answer: A. Use electrical tape to secure extension cords next to base boards on the floor
A nurse is caring for a client who has restraints to each extremity. Which of the following assessment
should the nurse perform first?
A. Elimination needs
B. Comfort level
C. Peripheral pulses
D. Skin integrity
Answer: C. Peripheral pulses
A nurse in a long-term care facility is assessing a client. Which of the following findings should the
nurse recognize as an indication a fecal impaction?
Answer: Seepage of liquid stool
A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse
take?
A. Cotton tip applicator to clean the inside of the cannula
B. Soak the outer cannula in warm soapy tap water
C. Cleanse the skin around the stoma with normal saline
D. Secure the tracheostomy ties to allow one finger to fit snuggly underneath
Answer: D. Secure the tracheostomy ties to allow one finger to fit snuggly underneath
A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate
action by the nurse?
Answer: I don't know of if I will be able to meet his physical needs.
A nurse is preparing to transfer a client who is partially weight bearing from the bed to a chair. Which
of the following action should the nurse
Answer: Have the client bear weight on her stronger leg
A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of the
following information should be nurse include in the hand off report?
Answer: Effectiveness of the last dose of pain medication
A nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the
following statements by the client indicates understanding of the teaching?
A. I will keep my eyes closed for 5 mins after inserting drops
B. I will insert the drops in the centre of the eye
C. I will press the inner corner of my eye after insert drops
D. I will raise my eye lid up while looking down and insert drops
Answer: C. I will press the inner corner of my eye after insert drops
A nurse in a long-term care facility is planning care for 4 clients. Which of the following client’s is at
greatest risk of developing a pressure ulcer?
A. A client who is incontinent of urine 1 to 2 times a day A client who is receiving enteral tube
B. feedings
C. Client who requires assistance to transfer from the bed to a chair
D. Client who is unresponsive to pain stimuli
Answer: D. Client who is unresponsive to pain stimuli
Listen to bowel sounds after performing abdominal palpation
A. Place diaphragm of stethoscope over each quadrant
B. Ask client to cough upon auscultating
C. Auscultate for 2 mins to determine if bowel sounds are active
Answer: A. Place diaphragm of stethoscope over each quadrant
