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ATI Fundamentals - ATI
Foundations of Nursing Practice (Emory University)
ATI Fundamentals Proctored Exam
1. The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym.
Which questions will the nurse ask the patient? (Select all that apply.)
a. Where did you fall?
b. What time did the fall occur?
c. What were you doing when you fell?
d. What types of injuries occurred after the fall?
e. Did you obtain an electronic safety alert device after the fall?
f. What are your medical problems that may have caused the fall?
Answer: A, B, C, D
Rationale:
Assess previous falls; using the acronym SPLATT:
Symptoms at time of fall
Previous
fall
Location of
fall
Activity at
time of fall
Time of fall
Trauma after fall
Medical diagnoses and an alert device are not components of SPLATT.
2. The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire
on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe.
Which actions will the nurse take? (Select all that apply.)
a. Close all doors.
b. Note evacuation routes.
c. Note oxygen shut-offs.
d. Move bedridden patients in their bed.
e. Wait until the fire department arrives to act.
f. Use type B fire extinguishers for electrical fires.
Answer: A, B, C, D
Rationale:
Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shutoffs is important in case evacuation is needed. You will move bedridden patients from the scene of
a fire by a stretcher, bed, or wheelchair. The nurse cannot wait until the fire department arrives to
act. Type C fire extinguishers are used for electrical fires; type B is used for flammable liquids.
3. The nurse is caring for a patient in restraints. Which essential information will the nurse
document in the patient’s medical record to provide safe care? (Select all that apply.)
a. One family member has gone to lunch.
b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
d. Straps with quick-release buckle attached to bed side rails
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed
Answer: B, C, E, F
Rationale:
Proper documentation, including the behaviors that necessitated the application of restraints, the
procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand),
and the evaluation of the patient response, is essential. Record nursing interventions, including
restraint alternatives tried, in nurses’ notes. Record purpose for restraint, type and location of
restraint used, time applied and discontinued, times restraint was released, and routine observations
(e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses’ notes and flow sheets.
Straps are not attached to side rails. Comments about the activities of one family member are not
necessarily required in nursing documentation of restraints.
1. A nurse is assessing body alignment. What is the nurse monitoring? The relationship of one body
part to another while in different
a. positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely
Answer: A
Rationale:
The terms body alignment and posture are similar and refer to the positioning of the joints,
tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the
individual’s center of gravity is stable. Body mechanics is a term used to describe the coordinated
efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in a direction to
oppose movement. Immobility is the inability to move about freely.
2. A nurse is providing range of motion to the shoulder and must perform external rotation. Which
action will the nurse take?
a. Moves patient’s arm in a full circle
b. Moves patient’s arm cross the body as far as possible
c. Moves patient’s arm behind body, keeping elbow straight
Moves patient’s arm until thumb is upward and lateral to head with
d. elbow flexed
Answer: D
Rationale:
External rotation: With elbow flexed, move arm until thumb is upward and lateral to head.
Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball-
and-socket joint.) Adduction: Lower arm sideways and across body as far as possible.
Hyperextension: Move arm behind body, keeping elbow straight.
3. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which
technique will the nurse use for each movement?
a. Each movement is repeated 5 times by the patient.
b. Each movement is performed until the patient experiences pain.
c. Each movement is completed quickly and smoothly by the nurse.
d. Each movement is moved just to the point of resistance by the nurse.
Answer: D
Rationale:
Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly,
just to the point of resistance; ROM should not cause pain. Never force a joint beyond its capacity.
Each movement needs to be repeated 5 times during the session. The patient moves all joints
through ROM unassisted in active ROM.
4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which
finding will indicate goal achievement for the nurse’s action?
a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures
Answer: D
Rationale:
Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in
joints not moved periodically through their full ROM. ROM exercises reduce the risk of
contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises
reduced contractures and improved active range of joint motion in affected lower extremities. Deep
breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate
hydration helps prevent renal calculi and urinary tract infections.
Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of
therapeutic devices to relieve pressure.
5. A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing
assistive personnel?
a. Determining the level of comfort
b. Changing the patient’s position
c. Identifying immobility hazards
d. Assessing circulation
Answer: B
Rationale:
The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel
(NAP). The nurse is responsible for assessing the patient’s level of comfort and for any hazards of
immobility and assessing circulation.
6. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment
will the nurse obtain to assess for this condition?
a. Thermometer
b. Elastic stockings
c. Blood pressure cuff
d. Sequential compression devices
Answer: C
Rationale:
A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than
20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, lightheadedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to
standing position. A thermometer is used to assess for fever. Elastic stockings and sequential
compression devices are used to prevent thrombus.
7. The patient has been in bed for several days and needs to be ambulated. Which action will the
nurse take first?
a. Maintain a narrow base of support.
b. Dangle the patient at the bedside.
c. Encourage isometric exercises
d. Suggest a high-calcium diet.
Answer: B
Rationale:
To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic
hypotension. Mobilize the patient as soon as the physical condition allows, even if this only
involves dangling at the bedside or moving to a chair. A wide base of support increases balance.
Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no
beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A
high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.
8. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which
condition will the nurse monitor for most closely in this patient?
a. Hypostatic pneumonia
b. Renal calculi
c. Pressure ulcers
d. Thrombus formation
Answer: B
Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters.
Immobilized patients are at risk for calculi because they frequently have hypercalcemia.
Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation.
Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis or
pooling of secretions. A pressure ulcer is an impairment of the skin that results from prolonged
ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets,
fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or
artery, which sometimes occludes the lumen of the vessel.
9. A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for
in this patient?
a. Increased appetite
b. Increased diarrhea
c. Increased metabolic rate
d. Altered nutrient metabolism
Answer: D
Rationale:
Immobility disrupts normal metabolic functioning: decreasing the metabolic rate, altering the
metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium
imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of
peristalsis, leading to constipation.
10. A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will
the nurse consider?
a. Loss of bone mass
b. Loss of strength
c. Loss of weight
d. Loss of hope
Answer: D
Rationale:
Loss of hope is a psychosocial aspect. Patients with restricted mobility may have some depression.
Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy,
dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. All the rest are
physiological aspects: bone mass, strength, and weight.
