2023 ATI Mental Health Proctored Exam With Answers-405 Solved Questions

16. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of
the following actions should the nurse take?
A. Follow a systematic pattern from side-to-side moving down the client’s chest
B. Ask the client to breathe in deeply through his nose
C. Instruct the client to sit erect with his head tilted slightly backward
D. Place the bell of the stethoscope on the client’s chest
Answer: A. Follow a systematic pattern from side-to-side moving down the client’s chest
Rationale:
When assessing breath sounds, the nurse should follow a systematic pattern from side-to-side
moving down the client’s chest to ensure all lung fields are assessed. Asking the client to
breathe in deeply through his nose (option b) may help elicit clearer breath sounds but is not
necessary for the assessment. Instructing the client to sit erect with his head tilted slightly
backward (option c) and placing the bell of the stethoscope on the client’s chest (option d) are
not appropriate actions for assessing breath sounds.
17. A home health nurse is teaching a client about home safety. Which of the following
statements by the client indicates an understanding of the teaching? (select ALL)
A. “I need to set my hot water heater to 140 degrees Fahrenheit”
B. “I will use the grab bars when getting in and out of the bathtub”
C. “I will apply tape over frayed areas of electrical cords”
D. “I need to have a fire escape plan with my family”
E “I need to check my medications for expiration dates”
Answer: B. “I will use the grab bars when getting in and out of the bathtub”
D. “I need to have a fire escape plan with my family”
E “I need to check my medications for expiration dates”
Rationale:
Using grab bars when getting in and out of the bathtub promotes safety and prevents falls
(option b). Having a fire escape plan with the family (option d) and checking medications for
expiration dates (option e) are important aspects of home safety. Setting the hot water heater
to 140 degrees Fahrenheit (option a) increases the risk of scalds and burns. Applying tape
over frayed areas of electrical cords (option c) does not address the underlying electrical
hazard and may create a fire risk.

18. A nurse is caring for a client preoperatively who has given informed consent for an
appendectomy. Which of the following statements by the client should the nurse address
first?
A. “I am afraid to walk if it hurts too much”
B. “I don’t understand why I need this surgery”
C. “I don’t want my family helping me after the surgery”
D. “I am afraid the scar will make me look disfigured”
Answer: B. “I don’t understand why I need this surgery”
Rationale:
Addressing the client's lack of understanding about the need for surgery is the priority to
ensure informed consent and promote client autonomy. The client's fear of walking due to
pain (option a), concerns about family assistance (option c), and fear of disfigurement (option
d) are important to address but are not as immediate as the need for clarification about the
necessity of the surgery.
19. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a
cast. Which of the following actions should the nurse take?
A. Place the shallow end of the fracture pan under the client’s buttocks
B. Encourage the client to try to defecate for 20 min while on the fracture pan
C. Keep the bed flat while the client is on the fracture pan
D. Hyperextend the client’s back while the fracture pan is in place
<fundamentals pg. 240 head of the bed to 30, never leave a client lying flat on bedpan,...
Answer: A. Place the shallow end of the fracture pan under the client’s buttocks
Rationale:
Placing the shallow end of the fracture pan under the client's buttocks ensures proper
positioning and comfort during defecation. This position allows the client's perineal area to be
properly aligned with the opening of the bedpan, facilitating elimination while minimizing
discomfort. Option b is incorrect because encouraging the client to try to defecate for 20
minutes can lead to unnecessary strain and discomfort, and it is not recommended to leave the
client on the bedpan for an extended period. Option c is incorrect because keeping the bed
flat may not provide the optimal angle for effective elimination. Option d is incorrect because
hyperextending the client's back can cause discomfort and may not facilitate proper
elimination.

20. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH
insulin. Which of the following statements by the client indicates an understanding of the
teaching?
A. “I should roll the NPH vial between my hands before drawing it up”
B. “I should draw up the NPH insulin before the regular insulin”
C. “I should inject air into the vial of regular insulin first”
D. “I should wait 10 minutes after mixing the insulin to inject it”

Answer: A. “I should roll the NPH vial between my hands before drawing it up”
Rationale:
Rolling the NPH insulin vial between the hands helps to mix the insulin suspension evenly
before drawing it up, ensuring consistent dosing. This step is essential to prevent inaccurate
insulin doses and maintain glycemic control. Option b is incorrect because NPH insulin
should be drawn up after the regular insulin to prevent contamination of the regular insulin
with NPH insulin. Option c is incorrect because injecting air into the vial of regular insulin
first is not necessary and may introduce air bubbles into the insulin, affecting the accuracy of
the dose. Option d is incorrect because waiting 10 minutes after mixing the insulin is not
necessary; once the insulin is properly mixed, it can be administered immediately.
21. A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of
the following actions should the nurse take before requesting a prescription for restraints
from the provider?
A. Place the client in a room away from the nurses’ station
B. Limit the client’s visitors
C. Give the client washcloths to fold
D. Close the door of the client’s room
Answer: C. Give the client washcloths to fold
Rationale:
Providing the client with washcloths to fold engages the client in a purposeful activity, which
can help redirect their attention and reduce agitation associated with confusion. This
intervention promotes safety and maintains the client's dignity while avoiding the
unnecessary use of restraints. Placing the client in a room away from the nurses' station
(option a), limiting visitors (option b), and closing the door (option d) do not address the

client's immediate need for redirection and may not be effective in preventing further
agitation.
22. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse
about an older adult client who has shingles. Which of the following information should the
nurse include in the report?
A. Where the client ate his breakfast
B. The times for routine vital sign measurements
C. The exact times the client had visitors
D. The type of transmission-based precautions in place
Answer: D. The type of transmission-based precautions in place
Rationale:
When providing a report about a client with shingles, it is essential to communicate the type
of transmission-based precautions in place to ensure the safety of both staff and other clients.
Shingles is caused by the varicella-zoster virus, and contact precautions are typically
implemented to prevent transmission. Knowing the specific precautions helps ensure proper
care and prevents the spread of infection. Information about where the client ate breakfast
(option a), routine vital sign measurements (option b), and visitor times (option c) is less
relevant to the immediate care needs of the client with shingles.
23. A nurse on a med-surg unit is teaching newly licensed nurse about tasks to delegate to AP.
Which of the following statements by the newly licensed nurse indicates an understanding of
the teaching?
A. “An AP may take orthostatic blood pressure measurements from a client who reports
dizziness” - RNs job since this requires ASESSMENT due to episode of adverse effect.
B. “An AP may monitor the peripheral IV insertion site of a client who is receiving
replacement fluids”- monitoring is part of assessment since it is using judgment
C. “An AP may perform a central line dressing change for a client who is ready for
discharge”
D. “An AP may count the respirations of a client who is going to have surgery later the same
day”- the client has surgery LATER that day, so this should mean that the patients condition
is not that urgent

Answer: D. “An AP may count the respirations of a client who is going to have surgery later
the same day”- the client has surgery LATER that day, so this should mean that the patients
condition is not that urgent
Rationale:
Delegating the task of counting respirations to an assistive personnel (AP) for a client who is
scheduled for surgery later the same day indicates an understanding of appropriate delegation
principles. Since the client's surgery is planned for later, their condition is stable enough to
allow an AP to perform routine tasks such as counting respirations. Tasks requiring
assessment or judgment should be performed by licensed nursing staff. Options a, b, and c
involve tasks that require assessment or judgment, which are outside the scope of practice for
an AP.
24. A nurse on a med-surg 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 procedures refuses to take
responsibility of her actions- please double check anyone
B. A client who has a new colostomy refuses to take instructions from the ostomy therapist
because she “doesn’t like him”
C. The family of a client who has a terminal illness asks that the provider not tell the client
the diagnosis
D. A client who has Crohn’s disease reports that his prescription drug plan will not pay for his
medications
Answer: A. A surgeon who removed the wrong kidney during a surgical procedures refuses
to take responsibility of her actions- please double check anyone
Rationale:
This scenario presents an ethical dilemma because it involves a surgeon who made a serious
error during a surgical procedure but refuses to take responsibility for her actions. This
situation raises questions about patient safety, accountability, and professional integrity.
Options b, c, and d describe challenging situations but do not necessarily involve ethical
dilemmas of the same magnitude as a healthcare provider refusing to accept responsibility for
a critical error.
25. A charge nurse on an acute care unit is planning care for a client. Which of the following
actions should the nurse take to promote the client’s continuity of care?

A. Plan to assign a different nurse to the client each shift
B. Limit the number of interdisciplinary team members managing the client’s care
C. Request that the client complete a satisfaction survey at discharge
D. Start discharge planning on the day of admission
Answer: D. Start discharge planning on the day of admission
Rationale:
Initiating discharge planning on the day of admission promotes continuity of care by allowing
early identification of the client's needs and potential discharge barriers. It provides ample
time for the interdisciplinary team to collaborate, address concerns, and develop a
comprehensive plan to ensure a smooth transition from hospital to home or another care
setting. Assigning a different nurse to the client each shift (option a) disrupts continuity of
care and may lead to inconsistencies in the client's treatment plan. Limiting the number of
interdisciplinary team members (option b) and requesting a satisfaction survey at discharge
(option c) are not directly related to promoting continuity of care.
26. A nurse is caring for a client who begins to experience a generalized seizure while
standing in her room. Which of the following actions should the nurse take?
A. Place a pad under the client’s head
B. Hold the client’s limbs tightly to prevent injury
C. Lift the client into bed with the help of other staff members (You assist them to fall)
D. Insert a bite block into the client’s mouth
Answer: A. Place a pad under the client’s head
C. Lift the client into bed with the help of other staff members (You assist them to fall)
Rationale:
PDF p 58: Advise all caregivers and family not to restrain the client during a seizure but to
lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put
him on his side with his head flexed slightly forward if possible, and loosen his clothing.
27. A nurse is caring for a client who is grieving the loss of her partner. The client states, “I
don’t see the point of living anymore.” Which of the following actions should the nurse take?
A. Recommend that the client seek spiritual guidance
B. Request that the client’s family provide additional support
C. Tell the client that this is a normal response to grief
D. Ask the client if she plans to harm herself

Answer: D. Ask the client if she plans to harm herself
Rationale:
The client's statement expressing a lack of motivation for living and questioning the point of
living anymore raises concerns about suicidal ideation. Therefore, the nurse should directly
ask the client if she plans to harm herself to assess her risk of self-harm and ensure
appropriate intervention and support are provided.
28. A nurse is planning care for a female client who has an indwelling urinary catheter. Which
of the following actions should the nurse include in the plan?
A. Empty the drainage bag at least every 8 hr
B. Keep the drainage bag at the level of the bladder
C. Use the clean technique to collect a specimen from the drainage system
D. Tape the catheter to the lower abdomen
Answer: C. Use the clean technique to collect a specimen from the drainage system
Rationale:
When collecting a specimen from the drainage system of an indwelling urinary catheter, the
nurse should use the clean technique to minimize the risk of introducing pathogens. Sterile
technique is not required for this procedure. Options a, b, and d are incorrect because they do
not address the proper technique for specimen collection from the urinary catheter drainage
system.
29. A nurse is providing teaching to an older adult client about home safety. Which of the
following information should the nurse include?
A. “Keep a nightlight on the bathroom”
B. “Set room temperature to 68 degrees Fahrenheit”
C. “Place throw rugs over electrical cords”
D. “Use chairs without arm rests”
Answer: A. “Keep a nightlight on the bathroom”
Rationale:
Older adults are at increased risk of falls, especially during nighttime bathroom trips.
Keeping a nightlight on in the bathroom helps provide visibility and reduces the risk of falls.
Options b, c, and d are incorrect because they do not directly address fall prevention
measures.

30. A nurse is planning care for a client who has a prescription for extremity restraints to both
wrists. Which of the following actions should the nurse include in the plan of care” (select
ALL)
A. Secure restrains to allow three fingers to slide under the restrains (1-2 fingers)
B. Ensure that the bed is in the lowest position
C. Tie each restraint with a quick-release knot
D. Attach the client’s restraints to the bed rail (to the bed frame)
E. Remove the client’s restraints every 2 hr
Answer: B. Ensure that the bed is in the lowest position
C. Tie each restraint with a quick-release knot
E. Remove the client’s restraints every 2 hr
Rationale:
Ensuring the bed is in the lowest position prevents injury if the client falls or attempts to get
out of bed. Tying restraints with quick-release knots allows for quick removal in case of an
emergency. Regular removal of restraints helps prevent complications such as skin
breakdown and muscle weakness. Options a and d are incorrect because securing restraints to
the bed rail and allowing only 1-2 fingers to slide under the restraints are no longer
considered best practices and may increase the risk of injury and complications.
31. 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” I think this is more for the physician
B. “The social worker will help you answer those questions”
C. “I think that you should discuss this with the hospice nurse”
D. “Try to help your dad enjoy this time as much as he can”
Answer: D. “Try to help your dad enjoy this time as much as he can”
Rationale:
Providing support and encouraging the client's son to focus on enhancing the quality of time
spent with his father is appropriate. This response acknowledges the client's son's concerns
while promoting positive coping strategies during a challenging time. Options a, b, and c may
redirect the focus away from addressing the client's son's immediate needs and concerns.

32. A nurse is caring for a client who will receive intermittent enteral feedings through a
gastrostomy tube. Which of the following actions should the nurse take when administering a
feeding? (select ALL)
A. Keep the client sitting upright for 15 min following administration
B. Instill the formula over a period of 30 to 45 min
C. Heat the formula to 80F prior to administration
D. Check for residual volumes by aspirating stomach contents
E. Place the client into the Fowler’s position
Answer: A. Keep the client sitting upright for 15 min following administration
B. Instil the formula over a period of 30 to 45 min
D. Check for residual volumes by aspirating stomach contents
E. Place the client into the Fowler’s position
Rationale:
Keeping the client upright after feeding helps prevent aspiration, instilling the formula slowly
reduces the risk of complications such as dumping syndrome, checking residual volumes
ensures adequate digestion and absorption, and positioning the client in Fowler's position
promotes optimal digestion and reduces the risk of aspiration. Option c is incorrect because
enteral formula should not be heated prior to administration as it can alter its composition and
cause nutrient degradation.
33. A nurse is preparing to administer metoprolol 25 mg PO every 12 hr. Available is
metoprolol 50 mg/scored tablet. How many tablets should the nurse administer with each
dose? (nearest tenth)
Answer: 25mg x (1 tablet/50mg) = 0.5 tablet
Rationale:
To calculate the number of tablets to administer, divide the desired dose by the dose available
per tablet. In this case, 25 mg divided by 50 mg per tablet equals 0.5 tablet.
34. A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the
following findings should the nurse report to the provider?
A. Potassium 5.5 mEq/L
B. Irritation of nasal mucosa
C. Sodium 144 mEq/L
D. Loose stools

Answer: A. Potassium 5.5 mEq/L
Rationale:
A potassium level of 5.5 mEq/L is above the normal range (3.5-5.0 mEq/L) and requires
further evaluation and possible intervention, as hyperkalemia can lead to cardiac
dysrhythmias and other serious complications. Options b, c, and d are within normal ranges
or expected findings for a client receiving tube feedings via NG tube.
35. A nurse is caring for a client who consumed 4 oz of juice, 16 oz of milk, 8 oz of coffee,
and 200 mL of water over an 8-hr period. Calculate the client’s intake for that 8-hr period
using millilters. (nearest whole number) 1oz = 30mL
Answer: 120mL (juice) + 480mL (milk) + 240mL (coffee) + 200mL (water) = 1,040mL
Rationale:
To calculate the total fluid intake, add the volumes of all fluids consumed over the specified
period. In this case, 4 oz of juice is equivalent to 120 mL, 16 oz of milk is equivalent to 480
mL, 8 oz of coffee is equivalent to 240 mL, and 200 mL of water, totaling 1,040 mL.
36. A nurse is providing discharge teaching to a client who does not speak the same language
as the nurse. Which of the following actions should the nurse take?
A. Use proper medical terms when giving instructions to the client.
B. Offer written instructions in the client’s language
C. Direct verbal discharge instructions to the interpreter (No, supposed to address the pt)
D. Request that an assistive personnel interpret that instructions for the client
Answer: B. Offer written instructions in the client’s language
C. Direct verbal discharge instructions to the interpreter (No, supposed to address the pt)
Rationale:
Address the client directly when the interpreter is present, Provide educational materials and
instructions in the client’s language.
37. A nurse is preparing to perform a sterile dressing change for a client. Which of the
following actions should the nurse plan to take?
A. Don sterile gloves prior to opening sterile dressing supplies
B. Set up the sterile field above waist level
C. Consider 5.08cm (2 in) of the sterile field’s border to be contaminated
D. Place the cap of a sterile solution inside the sterile field

Answer: B. Set up the sterile field above waist level
Rationale:
Setting up the sterile field above waist level helps maintain the sterility of the field by
minimizing the risk of contamination from airborne particles or contact with non-sterile
surfaces. Options a, c, and d are incorrect because sterile gloves should be donned after
opening sterile dressing supplies, considering a 5.08cm (2 in) border of the sterile field as
contaminated helps prevent accidental contamination, and the cap of a sterile solution should
not be placed inside the sterile field to avoid contamination.
38. 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 aspirate
C. Place the end of the NG tube in water to observe for bubbling
D. Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile water
Answer: B. Measure the pH of the gastric aspirate
Rationale:
Measuring the pH of the gastric aspirate helps verify the placement of the NG tube in the
stomach. Gastric aspirate typically has a pH of 1 to 5, indicating placement in the stomach.
Options a, c, and d are incorrect because assessing the gag reflex, observing for bubbling
when the tube is placed in water, and auscultating for air injection above the umbilicus are
not reliable methods for confirming NG tube placement.
39. A nurse is documenting in a client’s medical record. Which of the following entries
should the nurse record?
A. “Incision without redness or drainage”
B. “Drank adequate amounts of fluid with meals”
C. “Administered pain medication”
D. “Oral temperature slightly elevated at 0800”
Answer: C. “Administered pain medication”
Rationale:
Documenting the administration of pain medication is essential for maintaining accurate and
up-to-date records of the client's care. It provides a record of the interventions performed and

helps ensure continuity of care. Options a, b, and d may be relevant information but are not
examples of documentation of interventions performed.
41. A nurse is caring for a client who has a closed wound drainage system. Which of the
following actions should the nurse take?
A. Press straight down on the container to create a vacuum
B. Wear sterile gloves when emptying the container
C. Reset the container with the drainage port closed
D. Maintain the drain in a dependent position to facilitate drainage
Answer: A. Press straight down on the container to create a vacuum
Rationale:
Pressing straight down on the container helps create a vacuum, which promotes suction and
facilitates drainage from the wound. This action prevents air from entering the drainage
system, maintaining the integrity of the closed system. Option b is incorrect because wearing
sterile gloves is not necessary for emptying the drainage container; clean gloves are
sufficient. Option c is incorrect because resetting the container with the drainage port open
allows air to enter the system, potentially disrupting the vacuum. Option d is incorrect
because maintaining the drain in a dependent position does not directly affect the function of
the closed wound drainage system.
42. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to
care for corn
And calluses on her toes. Which of the following statements by the client indicates an
understanding of the teaching?
A. I can place an oval corn pad over toes that have corns as long asi remove the pad weekly
B. I should soak my feet in warm water daily to soften corns and calluses
C. I can apply lotion to soften calluses as long asi dont put lotion between my toes
D. I should use an over the counter liquid medication to remove corns
Answer: C. I can apply lotion to soften calluses as long asi dont put lotion between my toes
Rationale:
PDF p205: A qualified professional should perform foot care for clients who have diabetes
mellitus to evaluate the feet and prevent injury. Instruct clients at risk for injury to do the
following: inspect the feet daily, paying specific attention to the area between the toes; Use
lukewarm water, and dry the feet thoroughly; Apply moisturizer to the feet, but avoid

applying it between the toes; Avoid over‑the‑counter products that contain alcohol or other
strong chemicals; Avoid self‑treating corns or calluses; Do not apply heat unless prescribed.
43. 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?
A. Remove clocks from the clients room
B. Use full length side rails on the clients bed (considered a restraint)
C. Check on the client frequently while he is in the restroom (safety)
D. Encourage physical activity throughout the day to expend energy
Answer: C. Check on the client frequently while he is in the restroom (safety)
Rationale:
Checking on the client frequently while they are in the restroom is a proactive measure to
ensure their safety, especially if they are confused and at risk of falls or other accidents. This
approach helps prevent the need for restraints by providing supervision and assistance as
needed. Option a, removing clocks from the client's room, is not directly related to preventing
confusion-related behaviors. Option b, using full-length side rails, is considered a form of
restraint and should be avoided unless necessary for the client's safety. Option d, encouraging
physical activity, is generally beneficial but may not directly address the issue of confusion or
prevent the need for restraints.
44. A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. Contact
B. Droplets
C. Airborne
D. Protective environment
Answer: C. Airborne.
Rationale:
Tuberculosis (TB) is primarily transmitted through the airborne route via droplet nuclei
containing Mycobacterium tuberculosis. Therefore, airborne precautions should be initiated
to prevent the spread of TB to others. This includes placing the client in a negative pressure
room, wearing an N95 respirator mask when entering the room, and ensuring proper
ventilation. Options a, contact precautions, and b, droplet precautions, are not appropriate for
TB, as it is not primarily transmitted through direct contact or respiratory droplets. Option d,

protective environment precautions, is typically used for clients who are
immunocompromised to protect them from environmental pathogens, not for TB.
45. A nurse is planning to use nonpharmacological pain methods for a client who reports still
having mild back pain after receiving analgesia 1 hour ago. Which of the following actions
should the nurse include in the plan?
A. Encourage the client to apply a heating pad for 2 hours at a time
B. Apply an ice pack to the clients back for 1 hour
C. Remove distractions from the client’s room (distraction is good for the pt to get mind off
of pain)
D. Instruct the client to take deep, rhythmic breaths
Answer: D. Instruct the client to take deep, rhythmic breaths
Rationale:
PDF p 223: Avoid long applications of either heat or cold because this can result in tissue
damage, burns, and reflex vasodilation (with cold therapy). PDF p.233: Breathwork: Reduces
stress and increases relaxation through various breathing patterns
46. A nurse is teaching a client how to use an incentive spirometer. Which of the following
statements by the client indicates an understanding of the teaching?
A. I will try not to cough after using the spirometer (it’s good to cough up sputum)
B. I will use the spirometer three times a day (3-5x an hour)
C. I will initially hold my breath for 15 seconds (for inhalers)
D. I will seal my lips around the mouthpiece
Answer: D. I will seal my lips around the mouthpiece
Rationale:
Sealing the lips around the mouthpiece ensures proper technique when using the incentive
spirometer, allowing the client to effectively inhale and measure their lung capacity. Option a,
avoiding coughing after using the spirometer, is not ideal as coughing helps to clear
secretions from the airways. Option b, using the spirometer three times a day, may not
provide sufficient respiratory therapy compared to the recommended frequency of 3-5 times
per hour. Option c, holding the breath for 15 seconds, is not typically necessary when using
an incentive spirometer.

47. A nurse is preparing to provide foot care for a client. Identify the order in which the nurse
should perform the steps of foot care
A. Test the temperature of the water
B. Soak the client's feet in warm water
C. Use an orange stick to clean under the nails
D. Apply lotion to the client's feet
Answer: A. Test the temperature of the water
B. Soak the client's feet in warm water
C. Use an orange stick to clean under the nails
D. Apply lotion to the client's feet
Rationale:
The correct order for foot care is to first test the temperature of the water to prevent burns,
then soak the client's feet in warm water to soften the skin, followed by cleaning under the
nails with an orange stick to remove dirt and debris, and finally applying lotion to moisturize
the feet.
48. A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients.
Which of the following tasks should the charge nurse delegate to the AP?
A. Report ABG results to the provider
B. Instruct a client about how to use an incentive spirometer
C. Administer an enteral feeding to a client who has an established gastrostomy tube
D. Monitor the color of a client’s urinary output
Answer: D. Monitor the color of a client’s urinary output
Rationale:
Monitoring the color of a client's urinary output is a task that can be safely delegated to
assistive personnel (AP) as it involves observing and reporting findings rather than making
clinical judgments or performing invasive procedures. Options a, b, and c involve tasks that
require specialized knowledge or skill and should be performed by licensed nursing staff.
49. A nurse is interviewing a family as part of a family assessment. The nurse identifies the
family unit as a husband, a wife, and three children. One child is biological from this
marriage and the other two are from the wife’s previous marriage. The nurse should identify
this as which of the following family forms?
A. Extended

B. Blended
C. Nuclear
D. Alternative
Answer: C. Nuclear
Rationale:
A nuclear family consists of two parents (a husband and wife) and their biological or adopted
children living together as a unit. In this scenario, the family unit consists of a husband, a
wife, and three children, with one child being biological from the marriage and the other two
being from the wife's previous marriage. This fits the definition of a nuclear family.
50. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when
plugging in the IV pump. Which of the following actions should the nurse take first?
A. Obtain a replacement pump
B. Notify the biomedical department to fix the pump
C. Label the pump with a defective equipment sticker
D. Unplug the pump- unplugging will remove the source of potential fire started .
Answer: D. Unplug the pump- unplugging will remove the source of potential fire started .
Rationale:
Safety is the top priority when sparks are noted while plugging in the IV pump. Unplugging
the pump removes the potential fire hazard and ensures the immediate safety of the client and
staff. Options a, b, and c involve actions that can be taken after ensuring the immediate safety
of the environment by unplugging the pump.
51. A nurse is preparing to insert IV catheter for an adult client. Which of the following
actions should the nurse take?
A. Choose the most proximal site on the extremity selected (distal first)
B. Apply a cool compress for several minutes before insertion of the IV catheter (warm it)
C. Stroke the extremity for several minutes before insertion of the IV catheter
D. Place the tourniquet below the proposed insertion site (above it)
Answer: C. Stroke the extremity for several minutes before insertion of the IV catheter
Rationale:
Stroking the extremity helps dilate the veins, making them more prominent and easier to
access for IV insertion. This technique can enhance vein visibility and reduce the risk of
venous spasms during catheter insertion.

52. A nurse is providing teaching about preventing back strain to the caregiver of a client who
is immobile and requires assistance to reposition in bed. Which of the following statements
by the caregiver indicates an understanding of the teaching
A. I will place the bed in the lowest position (place at your hip level)
B. I will tighten my abdominal muscles prior to moving
C. I will keep my legs straight to provide more power in the lift (bend)
D. I will twist at the waist while pulling the draw sheet (avoid)
Answer: B. I will tighten my abdominal muscles prior to moving
Rationale:
PDF p71: Avoid twisting your thoracic spine and bending your back while your hips and
knees are straight; When lifting an object from the floor, flex your hips, knees, and back;
tighten the abdominal muscles to increase support to the back muscles
53. A nurse in an acute care facility is preparing to transfer a client to a long term care
facility.
Which of the following information should the nurse include in the hand off report?
A. Frequencyof previous vital sign measurement
B. Number of family members who have visited
C. Time of the clients last bath
D. Effectiveness of the last dose of pain medication
Answer: D. Effectiveness of the last dose of pain medication
Rationale:
PDF p39: Transfer documentation:
-Medical diagnosis and care providers
- Demographic information
-Overview of health status, plan of care, and recent progress
- Alterations that can precipitate an immediate concern
-Notification of assessments or care essential within the next few hours
-Most recent vital signs and medications, including PRN
- Allergies
- Diet and activity orders
-Specific equipment or adaptive devices (oxygen, suction, wheelchair)
-Advance directives and emergency code status

- Family involvement in care and health care proxy, if applicable
54. A nurse is assessing a client’s bowel sounds. Which of the following actions should the
nurse take?
A. Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate,
percuss palpate)
B. Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes)
C. Place the diaphragm of the stethoscope over each quadrant
D. Ask the client to cough upon auscultation (for lung assessment)
Answer: C. Place the diaphragm of the stethoscope over each quadrant
Rationale:
Placing the diaphragm of the stethoscope over each quadrant of the abdomen allows for
thorough auscultation of bowel sounds. This technique ensures that the nurse listens to all
areas of the abdomen to accurately assess bowel motility and detect any abnormalities.
Options a, b, and d are incorrect because they do not reflect the appropriate technique for
assessing bowel sounds.
55. A nurse is delegating client care to an assistive personnel. Which of the following tasks
should the nurse delegate?
A. Evaluating healing of an incision
B. Inserting a NG Tube
C. Performing a simple dressing change.
D. Changing IV tubing.
Answer: C. Performing a simple dressing change.
Rationale:
Performing a simple dressing change is a task that can be safely delegated to an assistive
personnel (AP) under the supervision of a nurse. It is within the scope of practice for an AP
and does not require the specialized knowledge or skills of a licensed nurse. Options A, B,
and D involve procedures that require nursing assessment, critical thinking, or technical skills
beyond the scope of an AP.
56. A nurse is screening several clients at a neighborhood health fair. Which of the following
assessment findings is the priority for referral for further care?
A. HR 105/min

B. BMI 25 kg/m2
C. BP 148/92
D. Glucose 45mg/dl
Answer: D. Glucose 45mg/dl
Rationale:
A glucose level of 45 mg/dl indicates hypoglycemia, which is an abnormal finding requiring
immediate attention and referral for further care. Hypoglycemia can lead to serious
complications, including loss of consciousness and seizures, if not promptly treated. Options
A, B, and C represent normal or borderline findings that may require further monitoring or
intervention but are not as immediately concerning as severe hypoglycemia.
57. A nurse is assessing a client’s extraocular eye movements. Which of the following actions
should the nurse take?
A. Position the client 6.1m(20ft) away from the Snellen chart.
B. Instruct the client to follow finger through the six cardinal position of gaze,
C. Ask the client to cover her right eye during assessment of her left eye.
D. Hold a finger 46cm (18inch) in front of the client’s eye.
Answer: B. Instruct the client to follow finger through the six cardinal position of gaze,
Rationale:
Assessing extraocular eye movements involves instructing the client to follow a finger
through the six cardinal positions of gaze. This assesses the function of the cranial nerves
responsible for eye movements. Options A, C, and D are not appropriate actions for assessing
extraocular eye movements.
58. Nurse is planning care for a client who has prescription of knee- length antibolic
stockings. Which of the following actions should the nurse take?
A. Remove the client’s stockings at least once each shift.
B. Roll the top of the client’s stocking down to just below the knee.
C. Seat the client in a chair for 30min prior to applying stockings
D. Measure the length of the client’s leg from the heel to gluteal fold.
Answer: A. Remove the client’s stockings at least once each shift.
Rationale:
Removing the client's stockings at least once each shift helps prevent complications such as
pressure injuries and impaired circulation. It also allows for inspection of the skin and

assessment of circulation. Options B, C, and D are incorrect because they do not promote
optimal circulation or prevent complications associated with prolonged use of anti-embolic
stockings.
59. A nurse is assessing a client’s oculomotor nerve functions. Which of the following actions
should the nurse take?
A. Check the client’s pupillary reaction to light
B. Ask the client to read print from the Snellen chart
C. Ask the client to identify diff scents
D. Use cotton to touch the client’s cornea lightly.
Answer: A. Check the client’s pupillary reaction to light
Rationale:
Assessing the pupillary reaction to light evaluates the function of the oculomotor nerve
(cranial nerve III), which controls the constriction of the pupil in response to light. This
assessment helps identify any abnormalities in cranial nerve function. Options B, C, and D
involve assessments of other cranial nerves or sensory functions unrelated to the oculomotor
nerve.
60. A nurse is planning to perform ear irrigation on an adult client who has impacted
cerumen. Which of the following should the nurse plan to take?
A. Wear sterile gloves while performing irrigation
B. Position the client with the affected side down following irrigation
C. Use cool fluid to irrigate the ear canal.
D. Pull the pinna downward during irrigation.
Answer: B. Position the client with the affected side down following irrigation
Rationale:
Positioning the client with the affected ear down following ear irrigation helps facilitate
drainage of the irrigation solution and any dislodged cerumen. This position allows gravity to
assist in removing debris from the ear canal. Options A, C, and D are incorrect because they
do not reflect the appropriate technique for ear irrigation or may cause discomfort to the
client.
61. A nurse is preparing to administer gentamicin 2mg/kg via IV bolus to a client who weighs
220lb. How many mg should the nurse administer?

Answer: 200mg
Rationale:
To calculate the dose of gentamicin, first, convert the client's weight from pounds to
kilograms:
220 lb ÷ 2.2 = 100 kg
Then, multiply the weight in kilograms by the dose of gentamicin:
100 kg × 2 mg/kg = 200 mg
Therefore, the nurse should administer 200 mg of gentamicin.
62. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client
informs the nurse that pain medication are not option for managing pain. Which of the
following is an appropriate response by the nurse?
A. I’m sure it will work if you just give it a chance?
B. You may take any herbal remedies you bring from home
C. Why do you think pain medication is not going to help you
D. Would you like me to give you a back massage?
Answer: D. Would you like me to give you a back massage?
Rationale:
Offering a back massage is a non-pharmacological pain management intervention that can
provide comfort and relaxation to the client. It respects the client's preference for not using
pain medication while offering an alternative pain relief option. Options A, B, and C do not
address the client's preference for non-medication pain management and may not be
appropriate or therapeutic responses.
63. A nurse is planning to discharge a client who has diabetes mellitus and a new prescription
for insulin. Which of the following actions should the nurse plan to complete first?
A. Provide the client with contact number for diabetes education specialist.
B. Obtain printed information on insulin self-administration
C. Make a copy of the medication reconciliation from for the client
D. Determine whether the client can afford the insulin administration supplies
Answer: D. Determine whether the client can afford the insulin administration supplies
Rationale:
Before discharge, it is essential to determine whether the client can afford the necessary
insulin administration supplies, such as syringes or insulin pens. This ensures that the client

will be able to adhere to the prescribed insulin regimen at home. Options A, B, and C are
important aspects of discharge planning but are not as immediate or essential as assessing the
client's ability to afford the supplies required for insulin administration.
64. A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the
following actions should the nurse take?
A. Allow the client to slide down his outstretched leg.
B. Place his arms around the client to prevent her fall.
C. Remain upright as the client falls toward him
D. Move quickly to a position in front of the client.
Answer: A. Allow the client to slide down his outstretched leg.
Rationale:
Allowing the client to slide down the nurse's outstretched leg provides support and a
controlled descent, reducing the risk of injury to both the client and the nurse. This action is a
recommended technique for guiding a falling client to the ground safely. Options B, C, and D
may increase the risk of injury to the client or the nurse and are not appropriate responses in
this situation.
65. A nurse is preparing to use the Z-track method to administer iron dextran to a client who
has iron-deficiency anaemia. The client asks why this method of injection is necessary.
Which of the following responses should the nurse make?
A. It decreases the risk of injecting medication into a blood vessel.
B. It delays medication absorption
C. It minimizes tissue irrigation
D. It accelerates medication excretion
Answer: A. It decreases the risk of injecting medication into a blood vessel.
Rationale:
The Z-track method is used to minimize the risk of medication leakage into subcutaneous
tissues or blood vessels by sealing the medication within muscle tissue. This technique helps
prevent irritation and staining of the subcutaneous tissue and minimizes the risk of adverse
effects associated with extravasation of the medication. Options B, C, and D are incorrect
because they do not accurately describe the purpose of the Z-track method or its benefits.

66. A nurse is conducting a health assessment for a client who take herbal supplements.
Which of the following statement by the client indicates an understand of the use of the
supplements?
A. I use garlic for my menopausal symptoms.
B. I use ginger when I get car sick
C. I take ginkgo biloba for headache
D. I take echinacea to control cholesterol
Answer: C. I take ginkgo biloba for headache
Rationale:
11 Proven Ginkgo Biloba Benefits
- Increases Concentration. ...
- Reduces Risk for Dementia and Alzheimer's. ...
- Helps Fight Anxiety and Depression. ...
- Fights Symptoms of PMS. ...
- Helps Maintain Vision and Eye Health. ...
- Helps Prevent or Treat ADHD. ...
- Improves Libido. ...
- Helps Treat Headaches and Migraines.
67. A nurse is caring for a client who has C-diff infection Which of the following actions
should the nurse take?
A. Give the client chlorhexidine gluconate for hand hygiene.
B. Remove the protective gown first when exiting the client's room
C. Use alcohol-based hand rub when caring for the client
D. Initiate contact precautions when providing client care
Answer: D. Initiate contact precautions when providing client care
Rationale:
Clostridium difficile (C. diff) infection is highly contagious and is spread through contact
with feces. Therefore, initiating contact precautions is essential to prevent the transmission of
the infection to other patients, healthcare workers, and visitors. Contact precautions include
wearing gloves and a gown when providing care to the infected client, as well as ensuring
proper hand hygiene using soap and water, as alcohol-based hand rubs are not effective
against C. diff spores.

68. A nurse is caring for a client who is scheduled for hip surgery in hr. Which of the
following actions is the nurse’s priority?
A. Ensure that the client has signed the consent form.
B. Lock the client’s valuable in a safe location
C. Verify that the client’s lab values are in the medical record.
D. Administer the prescribed preoperative sedative.
Answer: A. Ensure that the client has signed the consent form.
Rationale:
Ensuring that the client has signed the consent form for the hip surgery is the nurse's priority
because it ensures that the client has given informed consent for the procedure. Informed
consent is a legal and ethical requirement before any surgical intervention. The nurse must
verify that the consent form is correctly filled out, signed by the client or their legal
representative, and that the client understands the risks, benefits, and alternatives of the
surgery. This action helps to protect the client's autonomy and rights while ensuring that the
surgery proceeds safely and ethically.
69. A nurse is caring for a client who has prescription for morphine 5mg IM accidentally
administers the whole 10mg from the single dose vial. Which of the following actions should
the nurse take first?
A. Complete an incident report
B. Measure the client’s respiratory rate
C. Report the incident to the pharmacy.
D. Notify the client's provider
Answer: B. Measure the client’s respiratory rate
Rationale:
Accidentally administering an overdose of morphine, especially via the intramuscular (IM)
route, can lead to respiratory depression, which is a potentially life-threatening complication.
Therefore, the priority action for the nurse is to assess the client's respiratory status by
measuring the respiratory rate. Respiratory depression is a common adverse effect of opioids
like morphine, particularly with higher doses. Measuring the respiratory rate allows the nurse
to quickly identify any signs of respiratory distress or depression and initiate appropriate
interventions, such as administering naloxone or providing respiratory support. Once the
client's respiratory status is assessed and stabilized, the nurse can then proceed with other
necessary actions, such as completing an incident report and notifying the healthcare

provider. However, ensuring the client's safety by assessing respiratory status takes
precedence.
ATI FUNDAMENTALS
1. A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statements by a group member indicates that the teaching has been effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention
3. A nurse is planning care for a client who reports abdominal pain. An assessment by the
nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of
105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following
findings should be the nurse's priority?
Answer: Temperature
4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.
5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the le ft sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching?

Answer: "There are times I should use soap and water rather than alcohol based hand rub to
clean my hands."
7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15 min.
8. A nurse is providing teaching to a client who has heart failure about how to reduce his
daily intake of sodium. Which of the following factors is the most important in determining
the client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing
diarrhoea and who might have a right ear infection. Which of the following routes should the
nurse use to obtain the temperature?
Answer: Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client's
11. A nurse on a medical-surgical unit is admitting a client. Which of the following
information should the nurse document in the client's record first?
Answer: Assessment
12. A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?
Answer: The nurse washes with her hands held higher than her elbows

13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
15. A nurse is caring for an older adult client who becomes agitated when the nurse requests
that the client's dentures be removed prior to surgery. Which of the following responses
should the nurse make?
Answer: "What worries you about being without your teeth?"
16. A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse's religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning
self- injection of insulin. Which of the following statements should the nurse make?
Answer: "Tell me what I can do to help you overcome your fear of giving yourself
injections."
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness
19. A community health nurse is preparing a campaign about seasonal influenza. Which of
the following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations

20. A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse take first?
Answer: Perform hand hygiene
21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the
following actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers
23. A nurse in an emergency department is assessing a client who reports diarrhoea and
decreased urination for 4 days. Which of the following actions should the nurse take to assess
the client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
24. A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45 degree angle to the bed
27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of
the following actions by the nurse will improve the client's commitment to a long-term goal
of weight loss?
Answer: Attempt to increase the client's self-motivation

28. A nurse is caring for an older adult client who is violent and attempting to disconnect her
IV lines. The provider prescribes soft wrist restraints. Which of the following actions should
the nurse take while the client is in restraints?
Answer: Remove the restraints one at a time
29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand
30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for
ovarian cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: "I keep having nightmares about my upcoming surgery."
31. A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a
client. Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy care
33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the
operating room when the client states she no longer wants to have surgery. Which of the
following actions should the nurse take?
Answer: Notify the provider about the client's decision
35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in
the next month that might require a blood transfusion. The client expresses concern about the

risk of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
Answer: Donate autologous blood before the surgery
36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
who will have emergency surgery for appendicitis. Which of the following statements
indicates a lack of readiness to learn by the client?
Answer: The client reports severe pain
37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved
hand. The client has no documented bloodstream infection. Which of the following actions
should the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
39. A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
41. A nurse is caring for a client who is incontinent of loose stool and is reporting a painful
perineum. Which of the following is the priority nursing action?
Answer: Check the client's perineum

42. A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The
nurse suspects a wound infection because the drainage on the dressing is yellow and thick.
The nurse identifies this type of drainage as:
Answer: Purulent
43. A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's
specific gravity. The nurse knows the result will indicate the amount of:
Answer: Solutes in the urine
44. When obtaining a urine specimen for a culture and sensitivity from an indwelling
catheter, the nurse should:
Answer: Cleanse the entry port priot to withdrawing urine.
45. A client returning from the surgical suite following a vaginal hysterectomy is awake and
asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance
diet as tolerated." Which of the following is appropriate for the nurse to tell the patient?
Answer: I am going to listen to your abdomen
46. A nurse is caring for a client who is post-op following a partial colectomy. The patient has
a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and
asks the nurse when the NG tube will be taken out. Which of the following responses by the
nurse is appropriate at this time?
Answer: When the GI tract is working again, in about three to five days, the tube can be
removed.
47. A client develops a fecal impaction. Before digital removal of the mass, which type of
enema should the nurse give to loosen the feces?
Answer: Oil Retention
48. When a nurse makes an initial assessment of a client who is post-op following gastric
resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with
10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed.
Which of the following actions should the nurse take?
Answer: Notify the surgeon.

49. A nurse takes an older adult lient who has dysphagia following a CVA to the dining room
for dinner. When assisting the client at mealtime, the nurse should:
Answer: Offer the client tart or sour foods. (This makes it easier for them to swallow)
50. A client is admitted for evaluation and control of HTN. Several hours after the client's
admission, the nurse discovers the client supine on the floor, unresponsive to verbal or
painful stimuli. The nurse's first reaction at this time is to:
Answer: Establish an airway
51. A nurse is caring for several clients who are receiving O2 therapy. Which client should
the nurse assess most frequently for manifestations of oxygen toxicity?
Answer: 100% oxygen via partial rebreathing mask
52. A client is hospitalized for an infection of a surgical wound following abd surgery. To
promote healing and fight wound infection the nurse plans to arrange to increase the client's
intake of:
Answer: Vitamin C and Zinc
53. When communicating with a client who is hearing impaired, the nurse should
Answer: Face the client and speak slowly
54. An older adult client has been hospitalized on bed rest for 1 week. The client reports
elbow pain. Which of the following is an appropriate initial action for the nurse caring for
this client to take
Answer: Examine the elbow
55. A nurse is caring for a client who has a new prescription for tube feeding. The nurse
understands that the provider prescribed tube feeding because the client:
Answer: Is unable to swallow foods by mouth
56. CPR has been initiated for the client in the ER. The nurse understands that a critical
concept related to effective cardiac chest compressions is the need to:
Answer: Push hard and deep on the chest

57. A nurse is caring for a client who has just had a mastectomy and has a closed wound
suction device (hemovac) in place. Which nursing action will ensure proper operation of the
device?
Answer: Collapsing the device whenever its 1/2-2/3 full of air.
58. A client being discharged following abdominal surgery will be performing his own
dressing changes at home. It is most important for the nurse to include which of the following
in the discharge plan?
Answer: Demonstration of appropriate hand hygeine
59. The nurse is caring for an adult who has fluid volume excess. When weighing the client,
the nurse should
Answer: Weight the client upon rising.
60. A nurse is planning to collect a liquid stool specimen from a client for ova and parasites.
Inaccurate test results may result if the nurse:
Answer: Refrigerates the collected specimen
61. When replacing a client's surgical dressing, the nurse should:
Answer: Don clean gloves to remove the old dressing
62. A nurse is preparing to insert a NG tube for a client admitted with bowel obstruction.
Which of the following should the nurse do first?
Answer: Explain the procedure to the client.
63. A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both
hands and appears frightened. The appropriate nursing action is to
Answer: Ask if the patient is choking
64. Which nursing action prevents injury to a client' s eye during the administration of eye
drops
Answer: Holding the tip of the container above the conjunctival sac

65. When ambulating a frail, older adult client, the nurse should
Answer: Use the transfer belt if the client is unsteady
66. A client is recovering from gallbladder surgery performed under general anesthesia. The
nurse should encourage the client to use the incentive spirometer how many times per hour?
Answer: 4-5 times per hour
67. A client is recovering from an appendectomy for a ruptured appendix has a surgical
wound healing by secondary intention. When changing the client's dressing, which
observation should the nurse report to the client's surgeon?
Answer: A halo of erythemia on the surrounding skin
68. While changing the linen on the client's bed, the nurse should
Answer: Hold the linen away from his body and clothing.
69. A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the
following would be an unexpected finding when the nurse assesses the client's infusion line
and insertion site?
Answer: The area around the injection site feels warm when touched.
70. A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes
that the client's urine bag has been empty for 2 hours. The first action the nurse should take is
to:
Answer: Check to see if the tubing was kinked.
71. A client's provider has ordered that sputum specimen be collected for culture and
sensitivity. The nurse plans to collect this specimen...
Answer: In the morning upon rising.
72. The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The
nurse determines that the heimlich maneuver is necessary based on which finding:
Answer: Inability of the toddler to cry or speak

73. A client returns from surgery with two penrose drains in place. Anticipating frequent
dressing changes, what should the nurse use around the incision site?
Answer: Montgomery straps
74. A client who is post-op following laparotomy is reporting pain and dry mouth. The client
has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate
prescribed for the client the nurse should first
Answer: Measure the client's vital signs.
75. A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The
nurse realizes that the client needs further teaching when the client
Answer: Positions the irrigating solution bag 30 inchees above the stoma
76. A nurse is performing an eye irrigation for the client who has been exposed to smoke and
ash. Which of the following nursing actions should receive the highest priority during the
irrigation?
Answer: Wearing gloves during the procedure.
77. In planning care for a client with surgical wound helating by secondary intention, the
nurse can anticipate that the client will
Answer: Be at an increased susceptibility for infection.
78. A nurse is assessing a client admitted with sudden onset of severe back pain of unknow
origin. Which statement would be most effective for the nurse to use to elicit further
information from this client about his pain?
Answer: Tell me how you are feeling right now.
79. A nurse has inserted an indwelling catheter for a male patient. Where should the nurse
tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?
Answer: Lower abdomen
80. A nurse is in a public building when someone cries out "Help! I think he is having a heart
attack!" The nurse responds to the scene and finds the unconscious adult lying on the floor.

Another bystander has obtained an AED. The nurse's first action, after making certain
someone has called for EMS, should be to
Answer: Administer cardiac compressions.
81. A nurse is using the I-SBAR communication tool to provide the client's provider with
information about the client. The nurse should convey the client's pain status in which portion
of the report?
Answer: Assessment
82. A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower- intensity activities of daily
living. Which of the following activities should the nurse recommend to the client?
Answer: Washing dishes
83. A nurse in the emergency department is caring for a client who has abdominal trauma.
Which of the following assessment findings should the nurse identify as an indication of
hypovolemic shock?
Answer: Tachycardia
84. A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use first?
Answer: Inspection
85. A nurse is responding to a parent's question about his infant's expected physical
development during the first year of life. Which of the following information should the
nurse include?
Answer: A 10-month-old infant can pull up to a standing position.
86. A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
Answer: Observe the rate, depth, and character of the client's respirations.

87. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure.
The client states, "You are not putting that hose down my throat." Which of the following
statements should the nurse make?
Answer: "I can see that this is upsetting you."
88. An assistive personnel (AP) is assisting a nurse with the care of a female client who has
an indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching?
Answer: The AP hangs the collection bag at the level of the bladder.
89. A nurse is explaining the use of written consent forms to a newly- licensed nurse. The
nurse should ensure that a written consent form has been signed by which of the following
clients?
Answer: A client who has a prescription for a transfusion of packed red blood cells.
90. A nurse is planning care for a client who is postoperative and has a history of poor
nutritional intake. Which of the following actions should the nurse include in the plan of care
to promote wound healing?
Answer: Provide a protein intake of 1.5 g/kg of body weight per day.
91. A nurse is caring for a client who has a prescription for a vest restraint. Which of the
following actions should the nurse take?
Answer: Tie the restraint with a quick-release knot.
92. A nurse is performing a neurological assessment for a client. Which of the following
examinations should the nurse use to check the client's balance?
Answer: Romberg test
93. A nurse is caring for a client who has a fecal impaction. Before digital removal of the
mass, which of the following types of enemas should the nurse plan to administer to soften
the feces?
Answer: Oil retention

94. A nurse is caring for a client who has acute renal failure. Which of the following
assessments provides the most accurate measure of the client's fluid status?
Answer: Daily weight
95. A nurse is caring for a client who is 48 hr postoperative following a small bowel
resection. The client reports gas pains in the periumbilical area. The nurse should plan care
based on which of the following factors contributing to this postoperative complication?
Answer: Impaired peristalsis of the intestines
96. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive
spirometer. Which of the following instructions should the nurse include?
Answer: Cough deeply after each use.
97. A nurse is teaching a client who has lower extremity weakness how to use a four-point
crutch gait. Which of the following instructions should the nurse include in the teaching?
Answer: "Bear weight on both of your legs."
98. A nurse is called away for an emergency while conversing with a client who is concerned
about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of
the following ethical principles is the nurse demonstrating?
Answer: Fidelity
99. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the
following actions should the nurse direct the client to take first?
Answer: Remove the safety pin from the extinguisher.
100. A nurse is caring for a client who is receiving a blood transfusion. The client reports
flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The
nurse recognizes these manifestations as which of the following types of transfusion
reactions?
Answer: Hemolytic

101. A newly licensed nurse is preparing to administer medications to a client. The nurse
notes that the provider has prescribed a medication that is unfamiliar to her. Which of the
following actions should the nurse take?
Answer: Consult the medication reference book available on the unit.
102. A nurse is caring for a client who is postoperative following abdominal surgery. Which
of the following actions should the nurse take first after discovering that the client's wound
has eviscerated?
Answer: Cover the incision with a moist sterile dressing.
103. A nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take?
Answer: Position the client on his left side.
104. A nurse in a long-term care facility is admitting a client who is incontinent and smells
strongly of urine. His partner, who has been caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
Answer: "It must be difficult to care for someone who is confined to bed."
105. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe
atelectasis. Which of the following actions should the nurse plan to take?
Answer: Place the client in Trendelenburg's position.
106. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The
nurse should identify that which of the following findings is an indication of infiltration?
Answer: Edema at the infusion site
107. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure.
Which of the following actions should the nurse take?
Answer: Lower the client the floor and place a pad under the client's head.
108. A nurse is preparing to administer an intramuscular injection to a young adult client.
Which of the following injection sites is the safest for this client?
Answer: Ventrogluteal

109. A nurse is caring for a client who has bilateral casts on her hands. Which of the
following actions should the nurse take when assisting the client with feeding?
Answer: Sit at the bedside while feeding the client.
110. A nurse on a mental health unit is preparing to terminate the nurse-client relationship
with a client who no longer requires care. Which of the following concepts should the nurse
and client discuss in the termination phase of the relationship?
Answer: Loss
111. A nurse is providing education about cultural and religious traditions and rituals related
to death for the assistive personnel on the unit. Which of the following information should the
nurse include?
Answer: People who practice Judaism status with the body of the deceased until burial.
112. A nurse in a provider's office is collecting information from an older adult who reports
that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should
instruct the client that large doses of acetaminophen could cause which of the following
adverse effects?
Answer: Liver damage
113. A nurse is caring for a client who has a terminal illness. Which of the following findings
indicates that the client's death is imminent?
Answer: Cold extremities
114. A nurse is planning to document care provided for a client. Which of the following
abbreviations should the nurse use?
Answer: PC for after meals
115. A nurse is reviewing the laboratory values for a client who has a positive
Chvostek's sign. Which of the following laboratory findings should the nurse expect?
Answer: Decreased calcium

116. A nurse in a provider's office is reviewing the laboratory findings of a client who reports
chills and aching joints. The nurse should identify which of the following findings as an
indication that the client has an infection?
Answer: WBC 15,000 mm3
117. A nurse on a surgical unit is receiving a client who had abdominal surgery from the
postanaesthetic care unit. Which of the following assessments should the nurse make first?
Answer: Airway
118. A nurse is planning to perform passive range-of- motion exercises for a client.
Which of the following actions should the nurse take?
Answer: Repeat each joint motion five times during each session.
119. A nurse is caring for a client who has Clostridium difficile and is in contact isolation.
Which of the following actions should the nurse take?
Answer: Wear gloves when changing the client's gown.
120. A home health nurse is planning to provide health promotion activities for a group of
clients in the community. Which of the following activities is an example of the nurse
promoting primary prevention?
Answer: Educating clients about the recommended immunization schedule for adults
121. A nurse is teaching a client how to self-administer insulin. Which of the following
actions should the nurse take to evaluate the client's understanding of the process within the
psychomotor domain of learning?
Answer: Have the client demonstrate the procedure.
122. A client is being discharged home with oxygen therapy via a nasal cannula.
Which of the following instructions should the nurse provide to the client and family?
Answer: Wear cotton clothing to avoid static electricity.
123. A nurse in a provider's office is assessing a client who has heart failure. The client has
gained weight since her last visit and her ankles are oedematous. Which of the following
findings by the nurse is another clinical manifestation of fluid volume excess?

Answer: Bounding pulse
124. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The
client states "All this equipment is making me nervous." Which of the following responses
should the nurse make?
Answer: "All of this equipment can be frightening."
125. A nurse is providing oral care for a client who is unconscious. Which of the following
actions should the nurse take?
Answer: Place the client in a lateral position with the head turned to the side before
beginning the procedure.
126. An adolescent client in an outpatient mental health facility tells the nurse that it is hard
to follow his treatment plans because his friends discourage him. Which of the following
statements should the nurse make?
Answer: "Tell me more about how your friends discourage you."
127. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of
the following actions should the nurse take?
Answer: Fill the bag two-thirds full with ice.
128. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP).
Which of the following instructions should the nurse include?
Answer: When lifting an object, spread your feet apart to provide a wide base of support.
129. A nurse is providing teaching about food choices to a client who has a prescription for a
clear liquid diet. Which of the following selections by the client indicates an understanding of
the teaching?
Answer: Gelatin
130. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for
gastric decompression. Which of the following actions should the nurse include in the plan of
care? (Select all that apply)
Answer: 1. Provide oral hygiene frequently

2. Measure the drainage from the NG tube every shift
3. Secure the NG tube to the client's gown

ATI Fundamentals
1. A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and
has fluid volume deficit. Which of the following changes should the nurse identify as an
indication that the treatment was successful?
A. Decrease in heart rate
B. Increase in respiratory rate
C. Increase in blood pressure
D. Increase in body temperature
Answer: A. Decrease in heart rate
Rationale:
Fluid volume deficit commonly causes tachycardia as the body attempts to compensate for
decreased blood volume by increasing heart rate to maintain cardiac output. Administering
intravenous fluids to correct the deficit helps restore blood volume, leading to improved
tissue perfusion and decreased sympathetic nervous system activity. As fluid volume
increases, the heart does not need to work as hard to maintain cardiac output, resulting in a
decrease in heart rate, which indicates a successful response to fluid replacement therapy.
Therefore, the nurse should identify a decrease in heart rate as an indication that the treatment
was successful in addressing the fluid volume deficit.
2. A nurse working in the emergency department is witnessing the signing of informed
consent forms for the treatment of multiple clients during her shift. Which of the following
signatures may the nurse legally witness?
A. A 16 y/o client who is married
B. A 27 y/o who has schizophrenia
C. An adoptive parent who brings in his 8 yr son
D. A 17 year old mother who brings in her toddler.
Answer: C. An adoptive parent who brings in his 8 yr son
Rationale:

In most jurisdictions, the legal age of majority for providing informed consent for medical
treatment without parental involvement is typically 18 years old. However, there are
exceptions for minors under 18 years old who are legally emancipated, married, or parents
themselves. In this scenario, the adoptive parent legally has the authority to provide informed
consent for medical treatment for their 8-year-old son, as long as they have legal guardianship
or parental rights. Therefore, the nurse may legally witness the signature of the adoptive
parent bringing in his 8-year-old son for treatment.
3. 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?
A. Insert the catheter until resistance is met
B. Apply intermittent suctioning while withdrawing the catheter
C. Insert the catheter to the level of the carina
D. Use sterile water to lubricate the catheter
Answer: B. Apply intermittent suctioning while withdrawing the catheter
Rationale:
During nasotracheal suctioning, the nurse should apply intermittent suctioning while
withdrawing the catheter to avoid damaging the delicate tissues of the respiratory tract.
Inserting the catheter until resistance is met or to the level of the carina can cause trauma to
the airway. Using sterile water to lubricate the catheter is not recommended, as it can
introduce pathogens into the respiratory tract.
4. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of
the following foods should the nurse suggest that the client add to his diet?
A. Egg yolks
B. Whole milk
C. Avocado
D. Processed meats
Answer: C. Avocado
Rationale:
Avocado is a heart-healthy food that can help manage hypercholesterolemia due to its high
content of monounsaturated fats, which can help lower LDL (bad) cholesterol levels. Egg
yolks, whole milk, and processed meats are high in saturated fats and cholesterol, which can
raise LDL cholesterol levels and worsen hypercholesterolemia.

5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a
chair. After securing a safe environment, which of the following actions should the nurse take
next?
A. Stand facing the client
B. Place the chair at a 45-degree angle to the bed
C. Bend the client's knees to facilitate movement
D. Have the client flex the unaffected leg while standing
Answer: D. Have the client flex the unaffected leg while standing
Rationale:
Having the client flex the unaffected leg while standing helps to stabilize the client and
distribute weight evenly, reducing the risk of falls and injury during the transfer process.
Standing facing the client and placing the chair at a 45-degree angle to the bed are
appropriate steps, but having the client flex the unaffected leg is the next immediate action to
facilitate the transfer safely.
6. A nurse is caring for a group of clients. Which of the following should the nurse take to
prevent the spread of infection?
A. Use contact precautions for a client with Clostridium difficile infection
B. Encourage deep breathing exercises for a client with pneumonia
C. Assist with range of motion exercises for a client with a fractured femur
D. Use a clean dressing technique for a client with a stage III pressure ulcer
Answer: A. Use contact precautions for a client with Clostridium difficile infection
Rationale:
Clostridium difficile infection is transmitted via the fecal-oral route, so contact precautions,
including wearing gloves and a gown, are essential to prevent the spread of infection.
Encouraging deep breathing exercises, assisting with range of motion exercises, and using a
clean dressing technique are important aspects of care but do not directly address the
prevention of infection transmission.
7. A nurse is caring for a client who does not speak the same language as the nurse. When
working with the client through an interpreter, which of the following actions should the
nurse take?
A. Use family members as interpreters to ensure accurate communication

B. Speak directly to the interpreter rather than the client
C. Use medical jargon to convey information more efficiently
D. Allow the interpreter to translate the client's responses directly
Answer: D. Allow the interpreter to translate the client's responses directly
Rationale:
When working with an interpreter, the nurse should allow the interpreter to translate the
client's responses directly to ensure accurate communication. Using family members as
interpreters can compromise privacy and accuracy. The nurse should speak directly to the
client rather than the interpreter and use simple, non-medical language to enhance
understanding.
8. A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following assessment findings indicates that the catheter requires irrigation?
A. Presence of urine in the drainage bag
B. Pink-tinged urine in the drainage tubing
C. Complaints of suprapubic pain
D. Absence of urine output for 4 hr
Answer: B. Pink-tinged urine in the drainage tubing
Rationale:
Pink-tinged urine in the drainage tubing indicates the presence of blood, which can cause clot
formation and obstruction of the catheter. This finding suggests that the catheter requires
irrigation to maintain patency and ensure adequate urine drainage. Presence of urine in the
drainage bag, complaints of suprapubic pain, and absence of urine output may indicate other
issues but do not specifically indicate the need for catheter irrigation.
9. A nurse is caring for a client who has diarrhoea due to shigella. Which of the following
precautions should the nurse take?
A. Droplet precautions
B. Airborne precautions
C. Contact precautions
D. Standard precautions
Answer: C. Contact precautions
Rationale:

Shigella is transmitted via the fecal-oral route, so contact precautions are necessary to prevent
the spread of infection. Droplet precautions are used for infections transmitted via respiratory
droplets, while airborne precautions are used for infections transmitted via airborne particles.
Standard precautions are used for all clients to prevent the transmission of infections.
10. A nurse on a medical unit is preparing to discharge a client to home. Which of the
following actions should the nurse take as part of the medication reconciliation process?
A. Provide the client with a list of over-the-counter medications to avoid
B. Instruct the client to discontinue all medications upon discharge
C. Verify the client's current medication list with the pharmacy
D. Ensure the client has a 30-day supply of all prescribed medications
Answer: C. Verify the client's current medication list with the pharmacy
Rationale:
Medication reconciliation involves comparing the client's current medication list with the
medications ordered during the hospital stay to identify any discrepancies or changes.
Verifying the client's current medication list with the pharmacy ensures that the client's
medications are accurately documented and prescribed upon discharge. Providing the client
with a list of over-the-counter medications to avoid, instructing the client to discontinue all
medications, and ensuring a 30-day supply of medications may be components of discharge
teaching but are not specific to medication reconciliation.
11. A nurse is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid
therapy. Which of the following interventions should the nurse implement to prevent
infection?
A. Thread the catheter up to the hub reduces the risk of contamination along the length of the
catheter.
B. Inserting the catheter up to the hub reduces the risk of contamination along the length of
the catheter
Answer: B. Inserting the catheter up to the hub reduces the risk of contamination along the
length of the catheter
Rationale:
When inserting an IV catheter, advancing it up to the hub helps to ensure that the entire
length of the catheter is within the vein, minimizing the risk of contamination from external
sources. If the catheter is not inserted up to the hub, there is a possibility that a portion of the

catheter outside the vein could be exposed to potential contaminants, increasing the risk of
infection.
12. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound
healing. Which of the following food items should the nurse recommend as a good source of
complete protein?
A. Cheddar cheese
B. Complete proteins contain enough of all nine of the essential amino acids that help
maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of
complete protein.
Answer: B. Complete proteins contain enough of all nine of the essential amino acids that
help maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of
complete protein.
Rationale:
Complete proteins are those that contain all nine essential amino acids required by the body.
These amino acids are crucial for maintaining a positive nitrogen balance, which is essential
for processes such as wound healing. Foods like cheese, poultry, and fish are excellent
sources of complete protein, providing the body with all the essential amino acids it needs to
support tissue repair and maintain overall health.
13. A nurse is providing discharge teaching to a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the
client and his family?
A. Check the cord routinely for frays or tearing
B. Consider purchasing a generator for power backup
C. Observe for signs of hypoxia
D. Clothing and bedding should not be made from synthetic fabric b/c it can generate static
electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet
away from open flames (gas stove, fireplace).
Answer: D. Clothing and bedding should not be made from synthetic fabric b/c it can
generate static electricity, the client should wear cotton instead. Oxygen equipment should be
at least 10 feet away from open flames (gas stove, fireplace).
Rationale:

Clothing and bedding made from synthetic fabrics have the potential to generate static
electricity, which could pose a fire hazard in the presence of oxygen. Cotton materials are less
likely to generate static electricity, so they are safer for the client to wear and use in their
environment.
14. 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 hrs. Which of the following actions should the nurse take first?
A. Increase the IV infusion rate.
B. Assess the IV catheter for patency.
C. Notify the healthcare provider.
D. Document the findings in the client's chart.
Answer: B. Assess the IV catheter for patency.
Rationale:
Assessing the IV catheter for patency is the first action the nurse should take when the client
has received less fluid than expected. This helps to determine if there are any obstructions or
issues with the IV line that are preventing the proper infusion of fluids. Once patency is
confirmed, the nurse can then reassess the infusion rate and consider notifying the healthcare
provider if necessary.
15. A nurse is planning care for a client who has fluid overload. Which of the following
actions should the nurse plan to take first?
A. Administer diuretics as prescribed.
B. Restrict oral fluid intake.
C. Monitor intake and output.
D. Assess lung sounds for crackles.
Answer: A. Administer diuretics as prescribed.
Rationale:
Administering diuretics as prescribed is the first action the nurse should take when caring for
a client with fluid overload. Diuretics help to promote diuresis and reduce fluid volume,
which is essential for managing fluid overload. Restricting oral fluid intake may be necessary
but is not the first action to take. Monitoring intake and output and assessing lung sounds are
important aspects of care but come after administering diuretics to address the fluid overload.

16. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids.
Which of the following actions should the nurse take?
A. Select a large-gauge catheter for rapid fluid administration.
B. Use a tourniquet to visualize veins more easily.
C. Apply a warm compress to the selected vein to dilate it.
D. Choose a vein proximal to a joint to prevent infiltration.
Answer: C. Apply a warm compress to the selected vein to dilate it.
Rationale:
For older adult clients, veins may be more fragile and prone to collapse, making IV insertion
challenging. Applying a warm compress to the selected vein helps dilate it, making it easier
to visualize and access. This approach improves the chances of successful IV insertion with
minimal trauma to the client's veins.
17. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate
the pulmonary valve. Over which of the following locations should the nurse place the bell of
the stethoscope?
A. 2nd intercostal space, right sternal border
B. 2nd intercostal space, left sternal border
C. 4th intercostal space, left sternal border
D. 5th intercostal space, midclavicular line
Answer: A. 2nd intercostal space, right sternal border
Rationale:
To auscultate the pulmonary valve, the nurse should place the bell of the stethoscope at the
2nd intercostal space along the right sternal border. This location corresponds to the area
where the pulmonary valve can best be heard.
18. A nurse is caring for a client who has a terminal illness and is approaching death. The
client's respirations are noisy from secretions in her airway and she is short of breath.
Which of the following actions should the nurse take?
A. Administer oxygen therapy to improve oxygenation.
B. Suction the client's airway to remove secretions.
C. Elevate the head of the bed to facilitate breathing.
D. Provide comfort measures and reposition the client as needed.
Answer: D. Provide comfort measures and reposition the client as needed.

Rationale:
In the terminal stage of illness, the focus of care shifts towards providing comfort and dignity
to the client. Administering oxygen therapy may not be beneficial at this stage and could
potentially cause discomfort. Suctioning the airway may also be unnecessary and could lead
to further distress for the client. Elevating the head of the bed may help with breathing but
should be done in conjunction with providing comfort measures and repositioning the client
as needed to optimize comfort and alleviate distress.
19. A nurse is caring for a client who has a terminal diagnosis and whose health is declining.
The client requests information about advance directives. Which of the following responses
should the nurse make?
A. "I'll contact your healthcare provider to discuss your advance directives."
B. "Advance directives are not necessary at this point in your care."
C. "Let's discuss your preferences and values regarding your medical care."
D. "I can provide you with a brochure about advance directives."
Answer: C. "Let's discuss your preferences and values regarding your medical care."
Rationale:
It's essential for the nurse to engage the client in a conversation about their preferences and
values regarding medical care, especially as their health is declining. This approach allows
the nurse to provide individualized support and guidance in decision-making, respecting the
client's autonomy and dignity. Simply providing information or deferring to the healthcare
provider may not adequately address the client's needs and concerns regarding their end-oflife care.
20. 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?
A. "Is the pain sharp or dull?"
B. "On a scale of 1 to 10, how would you rate your pain?"
C. "Does the pain radiate to other areas?"
D. "Is the pain constant or intermittent?"
Answer: A. "Is the pain sharp or dull?"
Rationale:

Assessing the quality of pain helps the nurse understand its characteristics and potential
underlying causes. Asking whether the pain is sharp or dull can provide valuable information
about the nature of the pain sensation and guide further assessment and intervention. While
pain intensity (option b) is important, assessing its quality helps provide a more
comprehensive understanding of the client's pain experience.
21. A nurse is giving a change-of-shift report about a client he admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse to
provide?
A. The client's current vital signs.
B. The client's response to antibiotic therapy.
C. The client's oxygen saturation level.
D. The client's recent chest X-ray findings.
Answer: C. The client's oxygen saturation level.
Rationale:
In the case of pneumonia, monitoring oxygen saturation levels is crucial for assessing
respiratory status and ensuring adequate oxygenation. Changes in oxygen saturation can
indicate worsening respiratory function and may require immediate intervention. While other
pieces of information are important for comprehensive care, oxygen saturation takes priority
due to its direct relevance to the client's respiratory status.
22. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of
the following findings should the nurse expect?
A. Presence of erythema surrounding the ulcer.
B. Absence of pain at the ulcer site.
C. Formation of granulation tissue within the ulcer.
D. Discoloration of the surrounding skin.
Answer: D. Discoloration of the surrounding skin.
Rationale:
Discoloration of the surrounding skin is a common finding in pressure ulcers. This
discoloration may manifest as changes in skin colour, such as redness, purple, or darkening,
indicating tissue damage and compromised blood flow to the area. While erythema (option a)
may also be present, it is not specific to pressure ulcers. Pain at the ulcer site (option b) is

variable and may be present in some cases. Formation of granulation tissue (option c)
typically occurs during the healing process of a pressure ulcer.
23. A nurse is completing an admission assessment of an older adult client. Which of the
following findings should the nurse identify as a potential indication of abuse?
A. Bruising on the client's arms and legs.
B. Complaints of generalized weakness and fatigue.
C. Presence of bilateral pitting edema in the lower extremities.
D. Reluctance to speak or make eye contact with the nurse.
Answer: A. Bruising on the client's arms and legs.
Rationale:
Bruising on the client's arms and legs may indicate physical abuse, especially in the absence
of a reasonable explanation. Older adults are vulnerable to abuse, including physical abuse,
which may manifest as unexplained bruises or injuries. While complaints of weakness and
fatigue (option b) and bilateral pitting edema (option c) are concerning, they are not specific
indicators of abuse. Reluctance to speak or make eye contact (option d) may suggest
psychological distress but does not necessarily indicate abuse.
24. A nurse is caring for a client who is postoperative and has signs of haemorrhagic shock.
When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals
every 15 minute and call him back in 1 hour. From a legal perspective, which of the
following actions should the nurse take next?
A. Follow the surgeon's instructions and continue monitoring the client's vitals.
B. Implement interventions to stabilize the client's condition without waiting for further
instructions.
C. Seek a second opinion from another healthcare provider.
D. Document the surgeon's instructions and the client's condition in the medical record.
Answer: B. Implement interventions to stabilize the client's condition without waiting for
further instructions.
Rationale:
When a client is showing signs of haemorrhagic shock, immediate intervention is critical to
prevent further deterioration and potential harm. While it's important to follow the surgeon's
instructions, waiting for one hour without intervening could jeopardize the client's safety and
well-being. Nurses have a legal and ethical duty to provide appropriate and timely care to

clients, especially in emergency situations. Documenting the surgeon's instructions and the
client's condition (option d) is important for legal documentation but should not delay
necessary interventions in this scenario.
25. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV
catheter. After which of the following observations should the nurse remove the IV catheter?
A. Presence of redness and warmth at the insertion site.
B. Swelling and tenderness at the insertion site.
C. Formation of a small hematoma at the insertion site.
D. Infiltration of fluid around the insertion site.
Answer: D. Infiltration of fluid around the insertion site.
Rationale:
Infiltration occurs when fluid leaks into the surrounding tissue instead of entering the vein. It
can lead to swelling, discomfort, and compromised delivery of fluids or medications.
Removing the IV catheter is necessary to prevent further infiltration-related complications,
such as tissue damage or infection. While redness, warmth, swelling, tenderness, and
hematoma formation (options a, b, c) are all potential signs of complications at the insertion
site, infiltration requires immediate action to remove the catheter and assess for further
damage.
26. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the
nurse confirms the fire, which of the following actions should the nurse take next?
A. Evacuate the client from the room immediately.
B. Attempt to extinguish the fire using a fire extinguisher.
C. Close the door to the client's room to contain the fire.
D. Call for assistance from other staff members.
Answer: A. Evacuate the client from the room immediately.
Rationale:
The safety of the client is the nurse's priority in any emergency situation. In the event of a
fire, the nurse should evacuate the client from the area to ensure their safety. Option b may be
considered if the nurse can safely extinguish the fire without endangering themselves or the
client, but evacuation takes precedence. Closing the door (option c) may help contain the fire,
but it should not delay evacuation. Calling for assistance (option d) can be done after
ensuring the client's immediate safety.

27. A nurse in a provider's office is obtaining the health and medication history of a client
who has a respiratory infection. The client tells the nurse that she is not aware of any
allergies, but that she did develop a rash the last time she was taking an antibiotic.
Which of the following information should the nurse give to the client?
A. "It's important to inform your healthcare provider about your previous reaction to
antibiotics."
B. "You should avoid all antibiotics in the future to prevent allergic reactions."
C. "Your rash was likely caused by a viral infection rather than the antibiotic."
D. "You may have developed a temporary sensitivity to the antibiotic, but it should not cause
any future reactions."
Answer: A. "It's important to inform your healthcare provider about your previous reaction to
antibiotics."
Rationale:
The client's previous reaction to antibiotics, even if it resulted in a rash, could indicate a
potential allergy or sensitivity. It's crucial for the client to inform their healthcare provider
about this reaction to ensure appropriate prescribing of medications in the future. Options b,
c, and d provide inaccurate or potentially harmful information and do not address the
importance of communication with healthcare providers regarding medication reactions.
28. A home health nurse who has attended a training session for the therapeutic use of
aromatherapy with essential oils is planning to use this modality with some of her clients. For
which of the following clients should the nurse consult the provider before using this
complementary therapy?
A. A client with chronic pain.
B. A client with a history of anxiety.
C. A client with a history of migraines.
D. A client with a history of asthma.
Answer: D. A client with a history of asthma.
Rationale:
Aromatherapy with essential oils involves inhaling or applying concentrated plant extracts,
which can trigger respiratory symptoms in individuals with asthma or other respiratory
conditions. Consulting the provider before using aromatherapy is essential to ensure it is safe
for clients with respiratory conditions like asthma. While chronic pain (option a), anxiety

(option b), and migraines (option c) are all conditions that may benefit from aromatherapy,
they do not pose the same risk of exacerbation as asthma in response to essential oils.
29. A nurse on a medical-surgical unit is caring for a client who has a new prescription for
wrist restraints. Which of the following actions should the nurse take?
A. Apply the restraints with the client's wrists crossed to maximize security.
B. Secure the restraints to the side rails of the bed.
C. Remove the restraints every 4 hours to assess the client's condition.
D. Document the client's behavior justifying the use of restraints.
Answer: D. Document the client's behavior justifying the use of restraints.
Rationale:
Restraints should only be used when necessary to ensure the safety of the client or others and
should be applied according to facility policy and procedures. It's important for the nurse to
document the client's behavior or condition warranting the use of restraints, including
attempts at alternative interventions and ongoing assessment of the client's response to
restraint use. Options a and b may not be appropriate or safe restraint practices, and option c
is insufficient without documentation and assessment.
30. A nurse is caring for a client who is postoperative following knee arthroplasty and
requires the use of a thigh-length sequential compression device. Which of the following
actions should the nurse take?
A. Apply the sequential compression device with the client's leg in a dependent position.
B. Ensure the sequential compression device is snug but not too tight around the client's
thigh.
C. Encourage the client to ambulate frequently while wearing the sequential compression
device.
D. Remove the sequential compression device for 30 minutes every 4 hours.
Answer: B. Ensure the sequential compression device is snug but not too tight around the
client's thigh.
Rationale:
Proper application of sequential compression devices is crucial for their effectiveness and
safety. The device should be snug enough to provide compression and promote venous return
but not too tight to restrict circulation or cause discomfort. Option a is incorrect because the
leg should be elevated during application to promote venous return. Option c may be

appropriate for promoting circulation but is not specific to the use of the sequential
compression device. Option d is incorrect because the device should be worn continuously
unless contraindicated to prevent the risk of deep vein thrombosis (DVT) postoperatively.
31. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7
hours. The nurse should set the pump to deliver how many mL/Hr?
A. 107 mL/hr
B. 108 mL/hr
C. 106 mL/hr
D. 109 mL/hr
Answer: a) 107 mL/hr
Rationale:
Rate (mL/hr) = Total Volume (mL) / Time (hr)
Given:
Total Volume = 750 mL
Time = 7 hours
Substituting these values into the formula:
Rate = 750 mL / 7 hr
Rate = 107.14 mL/hr
So, the nurse should set the pump to deliver approximately 107.14 mL/hr.
32. 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?
A. Make sure the client wears a mask when outside her room if there is construction in the
area.
B. An allogeneic stem cell transplant compromises the client’s immune system, putting her at
risk for infection.
C. Encourage visitors to wear gloves and gowns when visiting the client.
D. Limit the client's exposure to sunlight.
Answer: B. An allogeneic stem cell transplant compromises the client’s immune system,
putting her at risk for infection.
Rationale:
Clients who have undergone an allogeneic stem cell transplant have weakened immune
systems due to the conditioning regimen and immunosuppressive medications. Therefore, it

is essential to maintain a protective environment to reduce the risk of infection. Options a, c,
and d are measures that may be appropriate for other situations but are not specifically related
to protecting the client with an allogeneic stem cell transplant from infection.
33. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
A. Administer the medication with the needle at a 45 degree angle.
B. Shake the medication vial vigorously before administration.
C. Massage the injection site after administration.
D. Inject the medication intramuscularly.
Answer: A. Administer the medication with the needle at a 45 degree angle.
Rationale:
Enoxaparin is a low molecular weight heparin that is administered subcutaneously. It should
be injected at a 45-degree angle into the subcutaneous tissue. Option b is incorrect because
shaking the medication vial vigorously is not recommended; it may cause bubbles to form,
which can affect the accuracy of the dose. Option c is incorrect because massaging the
injection site after administration can increase the risk of bruising or discomfort. Option d is
incorrect because enoxaparin should never be injected intramuscularly; it can lead to
hematoma formation and increased bleeding risk.
34. A nurse is caring for a child who has a prescription for a blood transfusion. The parents
have refused the treatment due to religious beliefs. Which of the following actions should the
nurse take?
A. Examine personal values about the issue.
B. The nurse should examine her own personal values about the issue to help her provide care
that is w/o bias.
Answer: B. The nurse should examine her own personal values about the issue to help her
provide care that is w/o bias.
Rationale:
In this situation, the nurse must respect the parents' religious beliefs while also ensuring the
child's well-being. By examining her own personal values, the nurse can identify any biases
that may affect her ability to provide care without judgment. This allows the nurse to deliver
care that is respectful and sensitive to the beliefs of the family while still advocating for the
child's health needs

35. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following
should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
A. 8 oz of ice chips
B. 6 oz of apple juice
C. 1 cup of water
D. 4 oz of yogurt
Answer: A. 8 oz of ice chips
Rationale:
In healthcare, fluid intake is typically measured in milliliters (mL). While the other options
are provided in fluid ounces or cups, the nurse should convert them to mL for accurate
documentation. 8 fluid ounces of ice chips is equivalent to approximately 240 mL, but since
some of the volume is lost due to melting, it is reasonable to document it as 120 mL on the
intake and output record.
36. A nurse is planning teaching for a group of adolescents who each recently had surgical
placement of an ostomy. Which of the following methods should the nurse use as a
psychomotor approach to learning?
A. Practice sessions
B. Lecture-style presentation
C. Reading handouts
D. Group discussion
Answer: A. Practice sessions
Rationale:
Adolescents often learn best through hands-on experiences and active participation. Practice
sessions allow them to physically engage in the learning process by practicing the skills
related to caring for their ostomies. This psychomotor approach helps reinforce learning
through muscle memory and increases their confidence in performing the necessary tasks
independently.
37. 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 the teaching?
A. Use tracheostomy covers when outdoors.

B. Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne
particles. In the home environment, medical asepsis with clean technique is appropriate.
Answer: B. Tracheostomy covers protect the client’s airway from cold air, dust, and other
airborne particles. In the home environment, medical asepsis with clean technique is
appropriate.
Rationale:
Tracheostomy covers are primarily used outdoors to protect the client's airway from
environmental contaminants such as cold air, dust, and other airborne particles. However, in
the home environment where cleanliness can be maintained, using medical asepsis with clean
technique is more appropriate for tracheostomy care. This ensures that the tracheostomy site
remains free from infection and complications.
38. A nurse is educating a client who has a terminal illness about her request to decline
resuscitation in her living will. The client asks what would happen if she arrived at the
emergency department and had difficulty breathing. Which of the following responses should
the nurse provide?
A. “We will apply oxygen through a tube in your nose.”
B. Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal
cannula.
Answer: B. Oxygen can provide comfort and is not resuscitative when the nurse delivers it
via nasal cannula.
Rationale:
In the context of a living will specifying a desire to decline resuscitation, the client is
expressing her wishes regarding end-of-life care. The nurse's response should align with the
client's preferences and provide accurate information. Oxygen administered via nasal cannula
is commonly used to relieve dyspnea and provide comfort to clients experiencing difficulty
breathing. This response reassures the client that oxygen therapy would be provided in a
manner consistent with her wishes and without initiating resuscitative measures.
39. A nurse is reviewing evidence-based practice principles about administration of oxygen
therapy with a newly licensed nurse. Which of the following actions should the nurse
include?
A. Regulate oxygen via nasal cannula at a flow rate no more than 6l/min
B. Administer oxygen via non-rebreather mask at a flow rate of 15 L/min.

C. Provide oxygen therapy to all patients regardless of oxygen saturation levels.
D. Increase oxygen flow rate as needed to maintain an SpO2 of 100%.
Answer: A. Regulate oxygen via nasal cannula at a flow rate no more than 6 L/min.
Rationale:
Evidence-based practice principles emphasize safe and effective oxygen administration to
prevent complications such as oxygen toxicity. Regulating oxygen via nasal cannula at a flow
rate no more than 6 L/min is supported by evidence to minimize the risk of oxygen-induced
respiratory depression and CO2 retention, particularly in patients with chronic obstructive
pulmonary disease (COPD). This action aligns with the nurse's responsibility to provide care
based on the best available evidence, promoting optimal patient outcomes.
40. 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)?
A. Assist the client with a partial bed bath
B. Measure the client's BP after the nurse administers an antihypertensive medication
C. Use a communication board to ask what the client wants for lunch
Answer: A. Assist the client with a partial bed bath
Rationale:
Assigning the task of assisting the client with a partial bed bath to an assistive personnel (AP)
is appropriate because it is within the AP's scope of practice and does not require specialized
nursing knowledge or skills. This task allows the AP to provide direct care to the client while
allowing the nurse to focus on assessments and interventions that require nursing expertise.
41. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the
following actions should the charge nurse identify as contaminating the sterile field?
A. Placing sterile items on a clean surface near the sterile field
B. Using sterile gloves to handle sterile equipment
C. Dropping a sterile instrument onto the sterile field
D. Reaching over the sterile field to grasp additional supplies
Answer: D. Reaching over the sterile field to grasp additional supplies
Rationale:
Reaching over the sterile field can introduce contaminants from the nurse's non-sterile
clothing or skin onto the sterile field, compromising its sterility. The other options describe

actions that maintain or compromise the sterility of the field to varying degrees, but reaching
over the sterile field poses a higher risk of contamination.
42. A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh
and expresses concern about skin cancer. Which of the following findings should the nurse
report to the provider as a possible indication of a skin malignancy?
A. Irregular borders
B. Symmetrical shape
C. Uniform color
D. Small size (less than 0.5 cm)
Answer: A. Irregular borders
Rationale:
Irregular borders are a characteristic feature of malignant skin lesions, such as melanoma.
Reporting this finding to the provider is essential for further evaluation and possible biopsy to
determine the nature of the lesion. Irregular borders suggest potential invasion and growth of
cancerous cells beyond the normal tissue boundaries, indicating the need for prompt
intervention and treatment.
43. A nurse is caring for a client who has an aggressive form of prostate cancer. The provider
briefly discusses treatment options and leaves the client's room. When the nurse asks if the
client would like to discuss any concerns, the client declines. Which of the following
statements should the nurse make?
A. "I understand it can be overwhelming to talk about your diagnosis. I'll be available if you
change your mind."
B. "It's important to discuss your treatment options with your provider. Let's talk about it
together."
C. "Would you like me to call your family to come and discuss your concerns?"
D. "If you don't talk about your concerns now, you might regret it later."
Answer: A. "I understand it can be overwhelming to talk about your diagnosis. I'll be
available if you change your mind."
Rationale:
Option a acknowledges the client's feelings and respects their decision to decline discussion
at this time while offering ongoing support and availability for future conversations. It

demonstrates empathy and understanding, fostering trust and rapport between the nurse and
the client.
44. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which
of the following actions should the nurse add to the client's plan of care?
A. Administering phenytoin as prescribed
B. Encouraging the client to ambulate independently
C. Placing the client in a prone position during a seizure
D. Ensuring a padded tongue blade is readily available
Answer: D. Ensuring a padded tongue blade is readily available
Rationale:
During a tonic-clonic seizure, the client may experience clenching of the jaw and potential
obstruction of the airway by the tongue. Having a padded tongue blade readily available
allows the nurse to safely manage the airway by gently inserting the blade between the teeth
to prevent tongue injury and maintain a clear airway. This action is crucial in preventing
complications and ensuring the client's safety during and after a seizure.
45. A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the
following findings should the nurse expect?
A. Increased urine output
B. Hypertension
C. Confusion
D. Bradycardia
Answer: C. Confusion
Rationale:
Hyponatremia, indicated by a sodium level of 125 mEq/L, can lead to neurological symptoms
such as confusion due to alterations in brain function caused by imbalanced sodium levels. As
sodium plays a crucial role in maintaining cellular function and water balance, low sodium
levels can affect neurological function, leading to confusion, lethargy, and potentially
seizures. Monitoring the client for signs of confusion is essential for early detection and
intervention to prevent further complications associated with hyponatremia.
46. A nurse is caring for a group of clients on a medical-surgical unit. In which of the
following situations does the nurse demonstrate the ethical principle of veracity?

A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the
nurse responded affirmatively.
B. Following the ethical principle of veracity, the nurse must tell the truth at all times and
never deceive others.
Answer: A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer,
and the nurse responded affirmatively.
Rationale:
Veracity refers to the ethical principle of truthfulness and honesty in communication. In this
scenario, the nurse demonstrates veracity by affirming the client's question truthfully, even
though it may be uncomfortable or challenging to disclose the information. Maintaining
honesty and transparency with the client is essential for building trust and fostering a
therapeutic relationship, even if the information shared is difficult to convey.
47. A nurse is auscultating the anterior chest wall of a client newly admitted to a medicalsurgical unit. Identify the type of breath sounds.
A. Wheezes
B. Crackles
C. Rhonchi
D. Vesicular
Answer: D. Vesicular
Rationale:
Vesicular breath sounds are soft, low-pitched, and heard over most of the lung fields during
inspiration. They are the normal breath sounds heard over healthy lung tissue. These sounds
are characterized by a rustling or swishing quality and are typically louder during inspiration
and softer during expiration.
48. A nurse is providing home care for a client who is receiving tube feedings and medication
through a gastrostomy tube. The family member providing the feedings reports that the client
has begun to have diarrhea. For which of the following practices should the nurse intervene?
A. Administering medications through the gastrostomy tube
B. Checking the position of the gastrostomy tube
C. Increasing the rate of tube feeding
D. Adding fiber supplements to the tube feeding formula
Answer: C. Increasing the rate of tube feeding

Rationale:
Diarrhea in a client receiving tube feedings through a gastrostomy tube can indicate
intolerance to the feeding or rapid administration of the formula. Increasing the rate of tube
feeding may exacerbate diarrhea and lead to dehydration and electrolyte imbalances.
Therefore, the nurse should intervene by assessing the client's tolerance to the current feeding
rate and considering adjustments based on the client's condition and response to the feeding.
49. A nurse has just inserted an NG tube for a client. Which of the following assessment
findings should the nurse expect to confirm correct tube placement?
A. Coughing and gagging
B. Breath sounds in the epigastric area
C. Absence of respiratory distress
D. Aspiration of gastric contents
Answer: D. Aspiration of gastric contents
Rationale:
Aspiration of gastric contents through the NG tube indicates correct placement of the tube in
the stomach. This finding confirms that the NG tube has been inserted properly and is
functioning as intended. It is essential to confirm correct placement before initiating any
enteral feedings or medication administration to prevent potential complications such as
aspiration pneumonia.
50. A nurse has an order to remove sutures from a client. After retrieving the suture removal
kit and applying sterile gloves, which of the following actions should the nurse take next?
A. Clean the sutured area with antiseptic solution
B. Ask the client about any discomfort or pain
C. Remove the sutures using the appropriate instrument
D. Apply a sterile dressing over the sutured area
Answer: B. Ask the client about any discomfort or pain
Rationale:
Before proceeding with the suture removal process, it is essential for the nurse to assess the
client's comfort level and inquire about any discomfort or pain experienced during the
procedure. This allows the nurse to address any concerns or provide pain management
measures as needed, ensuring the client's safety and comfort throughout the procedure.

51. A nurse in 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.
A. Obtain the pronouncement of death from the provider
B. Remove tubes and indwelling lines
C. Wash the client's body
D. Ask the client's family members if they would like to view the body
E. Place a name tag on the body
Answer: C. Wash the client's body
B. Remove tubes and indwelling lines
A. Obtain the pronouncement of death from the provider
D. Ask the client's family members if they would like to view the body
E. Place a name tag on the body
Rationale:
1. Wash the client's body: After a client has passed away, it's important to provide respectful
care by gently cleaning their body. This step ensures the client's dignity and comfort in their
final moments.
2. Remove tubes and indwelling lines: Once death has been confirmed, the nurse should
remove any medical equipment or lines that are no longer needed. This includes items such as
IV lines, oxygen tubes, and catheters.
3. Obtain the pronouncement of death from the provider: The next step is to officially
confirm the client's death by obtaining a pronouncement from the provider. This
documentation is necessary for legal and administrative purposes.
4. Ask the client's family members if they would like to view the body: After the client has
been prepared, the nurse should offer the opportunity for the family members to view the
body if they wish. This allows them to say their final goodbyes and begins the grieving
process.
5. Place a name tag on the body: Finally, the nurse should ensure that the client's body is
properly identified with a name tag. This helps maintain dignity and respect for the deceased
individual and ensures accurate identification during further handling or transfer.
52. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of
the following images should the nurse identify as indicating the correct technique for eliciting
the client's patellar reflex?
Here are the options for the images:

A. The nurse taps the client's Achilles tendon with a reflex hammer.
B. The nurse taps the client's biceps tendon with a reflex hammer.
C. The nurse taps the client's patellar tendon with a reflex hammer.
D. The nurse taps the client's radial tendon with a reflex hammer.
Answer: C. The nurse taps the client's patellar tendon with a reflex hammer.
Rationale:
The patellar reflex, also known as the knee-jerk reflex, is elicited by tapping the patellar
tendon, not the Achilles tendon, biceps tendon, or radial tendon. This technique stimulates the
stretch receptors in the quadriceps muscle, leading to a reflexive contraction and extension of
the lower leg. It is a commonly performed clinical assessment of neurological function.
53. A nurse is caring for a client who is postoperative. When the nurse prepares to change her
dressing she says, "Every time you change my bandage, it hurts so much" which of the
following interventions is the nurse's priority action?
A. Administer pain meds 45 minutes before changing the client’s dressing.
B. The priority action the nurse should take when using Maslow’s hierarchy of needs is to
meet the client’s physiological need for comfort and pain relief.
Answer: B. The priority action the nurse should take when using Maslow’s hierarchy of
needs is to meet the client’s physiological need for comfort and pain relief.
Rationale:
Maslow's hierarchy of needs prioritizes physiological needs, such as comfort and pain relief,
as fundamental to promoting well-being and facilitating recovery. Addressing the client's pain
during dressing changes is essential for promoting comfort, enhancing healing, and
improving the overall experience of care. Administering pain medication promptly helps
alleviate the client's discomfort and demonstrates a patient-centered approach to care.
54. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
A. "I will place the crutches under my arms and bear weight on my left leg."
B. "I will advance the crutches and my right leg at the same time."
C. "I will use my left leg to support my weight while using the crutches for balance."
D. "I will keep the crutches positioned close to my body when walking."
Answer: B. "I will advance the crutches and my right leg at the same time."

Rationale:
When using crutches, the client should advance the crutches and the opposite leg at the same
time to maintain balance and stability. This gait pattern, known as the three-point gait, helps
distribute weight evenly and prevents falls or strain on the injured limb. Understanding and
correctly verbalizing this instruction indicate that the client comprehends the proper
technique for using crutches.
55. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of
the following statements should the nurse identify as an indication that the client understands
the preoperative teaching she received about pain management?
A. "It might help me to listen to music while I'm lying in bed."
B. Listening to music is an effective non-pharmacological intervention for the management
of mild pain.
Answer: B. Listening to music is an effective non-pharmacological intervention for the
management of mild pain.
Rationale:
The client's statement reflects an understanding of the preoperative teaching about pain
management. By recognizing that listening to music can help alleviate mild pain, the client
demonstrates knowledge of non-pharmacological pain management strategies. This indicates
that the client has internalized the information provided during preoperative education and is
applying it to manage their pain effectively.
56. A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following
types of transmission precautions should the nurse initiate?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions
Answer: B. Droplet precautions
Rationale:
Diphtheria is primarily transmitted through respiratory droplets, so droplet precautions are
necessary to prevent the spread of the infection. This includes wearing a mask when within
close proximity to the client and ensuring proper hand hygiene. Droplet precautions also

involve placing the client in a private room or cohorting with other clients with the same
infection to minimize the risk of transmission to others.
57. A nurse is admitting a client who is having an exacerbation of heart failure. In planning
this client's care, when should the nurse initiate discharge planning?
A. After the client's condition stabilizes
B. Upon completion of the admission assessment
C. Once the client expresses readiness to be discharged
D. At the time of discharge
Answer: A. After the client's condition stabilizes
Rationale:
Discharge planning typically begins after the client's condition has stabilized and immediate
care needs have been addressed. In the case of a client with an exacerbation of heart failure,
the priority is to stabilize the client's condition, manage symptoms, and initiate appropriate
treatments. Once the client's condition has improved and they are medically stable, the nurse
can initiate discharge planning to ensure a safe transition from the hospital to home or
another care setting.
58. A middle adult client tells the nurse, "I feel so useless now that my children do not need
me anymore." Which of the following responses should the nurse make?
A. "People in middle adulthood often find satisfaction in nurturing and guiding young
people."
B. According to Erik Erikson, the task of middle adulthood is generativity versus selfabsorption and stagnation. The focus of this task is on offering support and guidance to future
generations. The nurse should explore with the client opportunities for mastering the
developmental tasks of this stage, such as volunteering and mentoring young people.
Answer: B. According to Erik Erikson, the task of middle adulthood is generativity versus
self-absorption and stagnation. The focus of this task is on offering support and guidance to
future generations. The nurse should explore with the client opportunities for mastering the
developmental tasks of this stage, such as volunteering and mentoring young people.
Rationale:
Option b is the most appropriate response because it acknowledges the client's feelings and
provides therapeutic guidance based on Erik Erikson's theory of psychosocial development.
Middle adulthood is characterized by the psychosocial task of generativity versus self-

absorption and stagnation. Generativity involves a concern for guiding and nurturing future
generations, whether through parenting, mentoring, or contributing to the community. By
exploring opportunities for the client to engage in activities that promote generativity, such as
volunteering or mentoring, the nurse assists the client in finding a sense of purpose and
fulfilment in this stage of life.
59. A nurse enters a client's room and finds her on the floor. The client's roommate reports
that the client fell out of bed. Which of the following statements should the nurse document?
A. "Client found lying on the floor next to the bed."
B. "Client fell out of bed, as reported by roommate."
C. "Client experienced an unwitnessed fall."
D. "Client was discovered on the floor by nurse during rounds."
Answer: B. "Client fell out of bed, as reported by roommate."
Rationale:
Option b provides a clear and concise documentation of the event, stating that the client fell
out of bed based on the report provided by the roommate. This statement accurately captures
the circumstances surrounding the fall and acknowledges the source of information. It is
important to document factual details of the incident, including the mechanism of injury and
any pertinent observations made by witnesses. This documentation serves as a record of the
event for communication among healthcare team members and for potential future reference.
60. A nurse is caring for a client who has recently started using a behind the ear hearing aid.
Which of the following statements should the nurse identify as an indication that she
understands the use of assistive devices?
A. "I will make sure to clean my hearing aid regularly with a soft, dry cloth."
B. "I need to place the hearing aid directly into my ear canal for it to work properly."
C. "I will turn up the volume on the hearing aid whenever I am in a noisy environment."
D. "It's important to remove the hearing aid before showering or swimming."
Answer: A. "I will make sure to clean my hearing aid regularly with a soft, dry cloth."
Rationale:
Proper maintenance and cleaning of a hearing aid are essential for optimal performance and
longevity. Using a soft, dry cloth to clean the hearing aid helps remove earwax, debris, and
moisture, which can affect sound quality and device function. This statement demonstrates

the client's understanding of the importance of care and maintenance practices associated
with assistive devices.
ATI Fundamentals
1. A nurse is teaching a group of older adults about expected changes of aging.
Which of the following statements by a group member indicates that the teaching has been
effective?
Answer: "I should expect my heart rate to take longer to return to normal after excessive as I
get older."
2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the
following abdominal assessments should the nurse expect?
Answer: Absent bowel sounds with distention
3. A nurse is planning care for a client who reports abdominal pain. An assessment by the
nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of
105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following
findings should be the nurse's priority?
Answer: Temperature
4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Answer: Administer analgesics to the child on a routine schedule throughout the day and
night.
5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Answer: Pericardial friction rub
6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene.
Which of the following statements by the AP indicates an understanding of the teaching?

Answer: "There are times I should use soap and water rather than alcohol based hand rub to
clean my hands."
7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes
by an electronic blood pressure machine. The nurse notices the machine begins to measure
the blood pressure at varied intervals and the readings are inconsistent. Which of the
following actions should the nurse take?
Answer: Discontinue the machine, and measure the blood pressure manually every 15
min.
8. A nurse is providing teaching to a client who has heart failure about how to reduce his
daily intake of sodium. Which of the following factors is the most important in determining
the client's ability to learn new dietary habits?
Answer: The involvement of the client in planning the change
9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing
diarrhoea and who might have a right ear infection. Which of the following routes should the
nurse use to obtain the temperature?
Answer: Temporal
10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
Answer: The signature on the preoperative consent form is the client’s
11. A nurse on a medical-surgical unit is admitting a client. Which of the following
information should the nurse document in the client’s record first?
Answer: Assessment
12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing techniques?
Answer: The nurse washes with her hands held higher than her elbows.

13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve?
Answer: Second intercostal space to the right of the sternum
14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which
of the following actions should the nurse take?
Answer: Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
15. A nurse is caring for an older adult client who becomes agitated when the nurse requests
the client’s dentures be removed prior to surgery. Which of the following responses should
the nurse make?
Answer: “What worries you about being without your teeth?”
16. A nurse is caring for a client who has a terminal illness. The client asks several questions
about the nurse’s religious beliefs related to death and dying. Which of the following actions
should the nurse take?
Answer: Encourage the client to express his thoughts about death and dying
17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning
self-injection of insulin. Which of the following statements should the nurse make?
Answer: “Tell me what I can do to help you overcome your fear of giving yourself
injections.”
18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Answer: Confirm unresponsiveness.
19. A community health nurse is preparing a campaign about seasonal influenza.
Which of the following plans should the nurse include as a secondary prevention?
Answer: Screening groups of older adults in nursing care facilities for early influenza
manifestations

20. A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse take first?
Answer: Perform hand hygiene
21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the
following actions should the nurse take?
Answer: Place the bladder of the cuff over the posterior aspect of the thigh
22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take first?
Answer: Identify the client using two identifiers
23. A nurse in an emergency department is assessing a client who reports diarrhoea and
decreased urination for 4 days. Which of the following actions should the nurse take to assess
the client's skin turgor?
Answer: Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
24. A nurse is providing teaching to an older adult client who has constipation. Which of the
following statements should the nurse include in the teaching?
Answer: "Sit on the toilet 30 minutes after eating a meal."
25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process?
Answer: Obtain client information
26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from
bed to a wheelchair. Which of the following techniques should the nurse use?
Answer: Place the wheelchair at a 45 degree angle to the bed
27. A nurse is planning weight loss strategies for a group of clients who are obese.
Which of the following actions by the nurse will improve the client's commitment to a longterm goal of weight loss?
Answer: Attempt to increase the client's self-motivation

28. A nurse is caring for an older adult client who is violent and attempting to disconnect her
IV lines. The provider prescribes soft wrist restraints. Which of the following actions should
the nurse take while the client is in restraints?
Answer: Remove the restraints one at a time
29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following
actions should the nurse take when she observes the client crying?
Answer: Sit and hold the client's hand
30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for
ovarian cancer. Which of the following statements by the client indicates she is experiencing
psychological distress?
Answer: "I keep having nightmares about my upcoming surgery."
31. A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment.
Answer: Inspect, Auscultate, Percuss, Palpate
32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a
client. Which of the following actions by the newly licensed nurse requires intervention?
Answer: Obtaining cotton balls for the tracheostomy care
33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
Answer: Evaluate pedal pulses
34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the
operating room when the client states she no longer wants to have surgery.
Which of the following actions should the nurse take?
Answer: Notify the provider about the client's decision
35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in
the next month that might require a blood transfusion. The client expresses concern about the

risk of acquiring an infection from the blood transfusion. Which of the following statements
should the nurse make to the client?
Answer: Donate autologous blood before the surgery
36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client
who will have emergency surgery for appendicitis. Which of the following statements
indicates a lack of readiness to learn by the client?
Answer: The client reports severe pain
37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a
regular size cuff for a client who is obese. Which of the following explanations should the
nurse give the AP
Answer: "Using a cuff that is too small will result in an inaccurately high reading."
38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved
hand. The client has no documented bloodstream infection. Which of the following actions
should the nurse take?
Answer: Carefully remove the gloves and follow with hand hygiene
39. A nurse is receiving a client from the PACU who is postoperative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
stretcher to the bed?
Answer: Lock the wheels on the bed and stretcher
40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Answer: Raise the level of the bed
ATI FUNDAMENTALS
1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse
understands that the most important aspect of had hygiene is the amount of
Answer: friction

2. A nurse is demonstrating postoperative deep breathing and coughing exercise to a client
about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client
maybe unprepared to learn if the client
Answer: reports severe pain
3. A client comes to the emergency department reporting that he has had diarrhoea for 4 days
and is urinating less than usual. When assessing the client’s skin turgor, the nurse should
Answer: grasp a fold of the skin on the chest under the clavicle, release it, and not the depth
of the impression
4. A nurse is planning interventions for a group of clients who are obese. What can the nurse
do to improve their commitment to a long-term goal of weight loss?
Answer: attempt to develop the client’s self- motivation
5. When admitting a client, the nurse records which information in the client’s record first?
Answer: assessment of the client
6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be
upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is
an appropriate nursing response?
Answer: Is there something about this procedure that concerns you?
7. A client who is unstable and requires frequent vital signs has an electronic blood pressure
machine automatically measuring his blood pressure every 15 min. However, the machine is
reading the client’s blood pressure at more frequent intervals, and the readings are not similar.
The nurse checks the machine settings and observes the additional readings, but the problem
continues. Which of the following is the appropriate nursing action?
Answer: Disconnect the machine, and measure the blood pressure manually every 15 min.
8. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is
resistant to learning self- injection of insulin and asks the nurse to administer all the
injections. The nurse explains the importance of learning self-care and appropriately adds
which of the following statements?
Answer: Tell me what I can do to help you overcome your fear of giving yourself injections.

9. An assistive personnel says to the nurse, “This client is incontinent of stool three or four
times a day. I get angry, and I think that the client is doing it just to get attention. I think we
should put adult diapers on her.” Which is the appropriate nursing response?
Answer: It is very upsetting to see an adult client regress.
10. A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated
that a moderate amount of blood loss is expected during the surgery, and the neighbor is
anxious about acquiring an infection from a blood transfusion. Which of the following is
appropriate for the nurse to suggest?
Answer: donating autologous blood before the surgery
11. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart
murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the
stethoscope at which location?
Answer: Second intercostals space to the right of the sternum
12. A client is admitted to the hospital with decreased circulation in the left leg. During the
admission assessment, which is the most important nursing action initially?
Answer: evaluate the pedal pulses
13. A nurse is caring for a client who requires rectal temperature monitoring. Available at the
client’s bedside is a thermometer is with a long, slender tip. Which of the following is the
appropriate action for the nurse to take?
Answer: obtain a thermometer with a short, blunt insertion end.
14. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of
sodium and cholesterol. The nurse understands that the most significant factor in planning
dietary changes for this client is the
Answer: involvement of the client in planning the change
15. A nurse is caring for an older adult client who is confused and continually grabs at the
nurses. Which of the following is an nursing action?
Answer: firmly tell the client not to grab

16. An assistive personnel tells the nurse, “I am unable to find a large blood pressure cuff for
a client who is obese. Can I just use the regular cuff if I can get it to stay on?” The nurse
replies that taking the blood pressure of a morbidly obese client with a regular blood pressure
cuff will result in a reading that is
Answer: high
17. Which of the following should the nurse do first when preparing to provide tracheostomy
care?
Answer: perform hand hygiene
18. A 3-year old child has had multiple tooth extractions while under general anesthesia. The
client returns from the postanaesthetic care crying, but awake, from the recovery room.Which
approach is likely to be successful?
Answer: Examine the mouth last
19. A nurse admits a client to a same-day surgery centre for an exploratory laparotomy
procedure this morning. The client’s surgeon asks the nurse to witness the signing of the
preoperative consent form. In signing the form as a witness, the nurse affirms that
Answer: the signature on the preoperative consent form is the client’s.
20. To use proper body mechanics while making an occupied bed for a client on bed rest, the
nurse should
Answer: place the bed in a high horizontal position
21. Which of the following should a group of community health nurses plan as part of a
primary prevention program for occupational pulmonary diseases?
Answer: elimination of the exposure
22. When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of
the following assessment findings prior to beginning chest compression?
Answer: absence of pulse

23. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a
back injury, which of the following techniques should the nurse use?
Answer: bend at the knees while maintaining a wide stance and a straight back, with the
client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae.
24. An older adult client appears agitated when the nurse requests that the client’s dentures be
removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the
following is an appropriate nursing response?
Answer: You seem worried. Are you concerned someone may see you without your teeth?
25. To use the nursing process correctly, the nurse must first
Answer: obtain information about the client
26. A postoperative client has been diagnosed with paralytic ileus. When performing
auscultation of the client’s abdomen, the nurse expects the bowel sounds to be
Answer: absent
27. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved
hands get spotted with blood. The client has not been diagnosed with any infection
transmitted via the bloodstream. Which of the following should the nurse do as soon as the
task is completed?
Answer: Remove the gloves carefully and follow with hand hygiene
28. A nurse is precepting a newly licensed nurse who is preparing to help a client perform
tracheotomy care. The nurse should intervene if the equipment the preceptee gathered
included
Answer: cotton balls
29. A nurse is caring for a client diagnosed with a terminal illness. The client asks several
questions about the nurse’s religious beliefs related to death and dying/ An appropriate
nursing response is to
Answer: encourage the client to express his thoughts about death and dying

30. When assessing a client’s heart sounds, the nurse hears a scratching sound during both
systole and diastole. These sounds become more distinct when the nurse has the client sit up
and lean forward.
Answer: The nurse should document the presence of a pericardial friction rub
31. A client admitted with abdominal pain tells the nurse that her father died recently, and she
begins crying while talking about him. The nurse determines that the client’s temperature is
39.2C (102.6F), her abdomen is soft without tenderness, and her menses is overdue by 2
days. To which observation should the nurse give priority attention?
Answer: The client’s menses is overdue
32. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing
technique by scrubbing
Answer: with her hands held higher than her elbows
33. A client scheduled for a hysterectomy has not yet signed the operative consent form.
When the nurse approaches the client and asks that she review and sign the form, the client
says she no longer wants to have the surgery. At this time, which action should the nurse
take?
Answer: ask the client why she has changed her mind.
34. A nurse prepares to admit a client who is immediately postoperative to the unit following
abdominal surgery. When transferring the client from the gurney to the bed, the nurse should
Answer: lock the wheels on the bed and stretcher
35. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the
client’s room to administer medications and finds the client crying/ The appropriate nursing is
to
Answer: sit and hold the client’s hand.
36. Steps used for abdominal assessment
Answer: inspection, auscultation, percussion, palpation
37. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate.

Which nursing action is appropriate?
Answer: count the apical pulse rate for 1 full min, and describe the rhythm in the chart.
38. A nurse is caring for a client who has hypertension. Which approach is the priority when
the nurse is measuring the client’s blood pressure?
Answer: obtain the blood pressure under the same conditions each time.
39. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit
and says that they are sending a transporter for the client. When entering the client’s room,
the priority action is to
Answer: check the client’s identification bracelet.
40. An older adult client just diagnosed with colon cancer asks the nurse what the primary
care provider is going to do. The provider will be making rounds within the hour. Which of
the following nursing actions is appropriate?
Answer: help the client write down the questions to ask the provider, so that the client
doesn’t forget.