ATI RN fundamentals complete structured exam with correct question and
answers Rated A++ latest.
1. A nurse is giving change-of-shift report about a patient they admitted earlier that day who has
pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
A. Admitting diagnosis
B. Breath sounds
C. Body Temperature
D. Diagnostic test results
Answer: B. Breath sounds
Rationale: When using the airway, breathing, circulation approach to patient care, the nurse
should determine that the priority information to provide is the current status of the patient's
breath sounds.
2. A nurse is caring for a patient who has an NG tube and is receiving intermittent feedings
through an open system. Which of the following actions should the nurse take first?
A. Rinse the feeding bag with water between feedings.
B. Tell the patient to keep the head of the bed elevated at least 30º.
C. Make sure the enteral formula is at room temperature.
D. Wipe the top of the formula can with alcohol.
Answer: B. Tell the patient to keep the head of the bed elevated at least 30º.
Rationale: The first action the nurse should take when using the airway, breathing, circulation
approach to patient care is to prevent aspiration of the enteral formula; therefore, the priority
intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula
into the esophagus.
3. A nurse is caring for a patient who has tuberculosis. Which of the following actions should the
nurse take? (Select all that apply.)
A. Place the patient in a room with negative pressure airflow.
B. Wear gloves when assisting the patient with oral care.
C. Limit each visitor to 2-hr increments.
D. Wear a surgical mask when providing patient care.
E. Use antimicrobial sanitizer for hand hygiene.
Answer: A, B, E
Rationale: • Place the patient in a room with negative-pressure airflow is correct. The nurse
should place the patient in a room with negative-pressure airflow to meet the requirements of
airborne precautions.
• Wear gloves when assisting the patient with oral care is correct. The nurse should wear gloves
when assisting the patient with oral care to meet the requirements of standard precautions, which
the nurse must adhere to for all patients regardless of their diagnosis. The nurse should wear
gloves whenever their hands might come in contact with a patient's bodily fluids, such as saliva,
and the mucous membranes in the mouth.
• Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the patient's
visitors. However, the nurse should limit the patient's presence outside the room and the patient
should wear a surgical mask when outside of the room.
• Wear a surgical mask when providing patient care is incorrect. The nurse should wear an N95
respirator during patient care to meet the requirements of airborne precautions.
• Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial
sanitizer for routine hand hygiene when caring for a patient who has tuberculosis. Nurses should
also wash their hands with soap and water when their hands are visibly soiled.
4. A nurse is performing a Romberg test during the physical assessment of a patient. Which of
the following techniques should the nurse use?
A. Touch the face with a cotton ball.
B. Apply a vibrating tuning fork to the patient's forehead.
C. Have the patient stand with their arms at their sides and their feet together.
D. Perform direct percussion over the area of the kidneys.
Answer: C. Have the patient stand with their arms at their sides and their feet together.
Rationale: A Romberg test helps identify alterations in balance. The nurse should have the
patient stand with their arms at their sides and their feet together to observe for swaying and a
loss of balance.
5. A nurse is preparing to obtain a lower extremity blood pressure from a patient and no longer
palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the
measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood
pressure?
A. 92 mm Hg
B. 102 mm Hg
C. 112 mm Hg
D. 122 mm Hg
Answer: D. 122 mm Hg
Rationale: To obtain an accurate blood pressure measurement, the nurse should inflate the cuff
30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last
palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse
should inflate the cuff.
6. A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine
stat" for a patient who has myxoedema coma. How should the nurse transcribe the dosage of this
medication in the patient's medical record?
A. .3 mg
B. 0.3 mg
C. 0.30 mg
D. 3/10 mg
Answer: B. 0.3 mg
Rationale: The use and placement of a decimal point can potentially cause a medication error if
documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not
follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
7. A nurse is discussing the use of herbal supplements for health promotion with a patient. Which
of the following patient statements indicates an understanding of herbal supplement use?
A. "I can take echinacea to improve my immune system."
B. "I can take feverfew to reduce my level of anxiety."
C. "I can take ginger to improve my memory."
D. "I can take ginkgo biloba to relieve nausea."
Answer: A. "I can take echinacea to improve my immune system."
Rationale: Echinacea is taken to promote immunity and reduce the risk of infection.
8. A nurse is caring for a patient who has decreased mobility. Which of the following actions
should the nurse take to decrease the patient's risk of developing plantar flexion contractures?
A. Place a pillow under the patient's knees.
B. Position a trochanter roll under each of the patient's hips.
C. Advise the patient to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the patient's feet.
Answer: D. Apply an ankle-foot orthotic device to the patient's feet.
Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic
device or a foot board placed perpendicular to the mattress.
9. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the
following interventions should the nurse include that is within the RN scope of practice?
A. Insert an implanted port.
B. Close a laceration with sutures.
C. Place an endotracheal tube.
D. Initiate an enteral feeding through a gastrostomy tube.
Answer: D. Initiate an enteral feeding through a gastrostomy tube.
Rationale: It is within the RN scope of practice for nurses to initiate enteral feedings through
nasoenteric, gastrostomy, and jejunostomy tubes.
10. A nurse is planning care for a patient who has vision loss. Which of the following
interventions should the nurse include in the plan of care to assist the patient with feeding?
A. Assign a staff member to feed the patient.
B. Provide small-handled utensils for the patient.
C. Thicken liquids on the patient's tray.
D. Arrange food in a consistent pattern on the patient's plate.
Answer: D. Arrange food in a consistent pattern on the patient's plate.
Rationale: Consistency in preparing the patient's plate helps to facilitate self-feeding for patients
who have vision loss. Staff can describe the location of the food on the plate by using a clock
pattern, allowing the patient to have greater independence during meals.
11. A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing
change. Which of the following actions by the newly licensed nurse requires intervention by the
charge nurse?
A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile
field.
B. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field.
C. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when
pouring.
D. The sterile field is positioned at the level of the newly licensed nurse's waist.
Answer: A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the
sterile field.
Rationale: The newly licensed nurse should place the cap with the sterile side up on a clean
surface because the outer edges are unsterile and will contaminate the sterile field.
12. A nurse is reviewing protocol in preparation for suctioning secretions from a patient who has
a new tracheostomy. Which of the following actions should the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.
Answer: B. Select a suction catheter that is half the size of the lumen.
Rationale: The nurse should select a suction catheter that is half the size of the lumen to prevent
hypoxemia and trauma to the mucosa.
13. A nurse in a clinic is caring for a middle adult patient who states, "The doctor says that, since
I am at an average risk for colon cancer, I should have a routine screening. What does that
involve?" Which of the following responses should the nurse make?
A. "I'll get a blood sample from you and send it for a screening test."
B. "Beginning at age 60, you should have a colonoscopy."
C. "You should have a fecal occult blood test every year."
D. "The recommendation is to have a sigmoidoscopy every 10 years."
Answer: C. "You should have a fecal occult blood test every year."
Rationale: Colorectal cancer screening for patients who are at average risk begins at age 50. One
option for screening is a fecal occult blood test annually.
14. A nurse has just inserted an NG tube for a patient. Which of the following findings should the
nurse expect to confirm correct tube placement?
A. The tube aspirate has a pH of 7.
B. An x-ray shows the end of the tube above the pylorus.
C. Bowel sounds are present on auscultation.
D. The patient reports relief of nausea.
Answer: B. An x-ray shows the end of the tube above the pylorus.
Rationale: An abdominal x-ray showing the end of the tube above the pylorus indicates gastric
placement.
15. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a patient.
Which of the following actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the patient in a semi-Fowler's position prior to medication administration.
D. Verify the dosage by measuring the liquid before administering it.
Answer: A. Gently shake the container of medication prior to administration.
Rationale: The nurse should gently shake the liquid medication to ensure that the medication is
mixed.
16. A nurse is admitting a patient who has rubella. Which of the following types of transmission
based precautions should the nurse initiate?
A. Droplet
B. Airborne
C. Contact
D. Protective environment
Answer: A. Droplet
Rationale: Droplet precautions are a requirement for patients who have infections that spread
via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis.
17. A nurse is reviewing a patient's medication prescription that reads, "digoxin 0.25 by mouth
every day." Which of the following components of the prescription should the nurse verify with
the provider?
A. Medication name
B. Route of administration
C. Medication dose
D. Frequency of administration
Answer: C. Medication dose
Rationale: In the prescription, the medication dose is not complete. The number 0.25 should be
followed by a unit of measurement, such as mg, to clarify the amount the nurse should
administer.
18. A nurse manager is overseeing the care activities on a unit. For which of the following
situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A. A nurse who is caring for a patient reviews the patient's medical chart with a nursing student
who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a patient.
C. A nurse who is caring for a patient returns a call to the person appointed in the health care
proxy to discuss the patient's care.
D. A nurse discusses a patient's status with the physical therapist who is caring for the patient.
Answer: B. A nurse asks a nurse from another unit to assist with documentation for a patient.
Rationale: Only health care professionals directly caring for a patient should have access to the
patient's medical information; therefore, this is a violation of HIPAA guidelines.
19. A nurse is teaching an older adult patient who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the nurse
recommend?
A. Walking briskly
B. Riding a bicycle
C. Performing isometric exercises
D. Engaging in high-impact aerobics
Answer: A. Walking briskly
Rationale: Weight-bearing exercises are essential for maintaining bone mass, which helps to
prevent osteoporosis. Walking engages older adult patients in this preventive and therapeutic
strategy.
20. A nurse is caring for a patient who requires an informed consent for a surgical procedure.
Which of the following actions is the nurse's responsibility?
A. Describe the procedure to the patient.
B. Witness the patient's signature on the consent form.
C. Inform the patient of alternatives to the procedure.
D. Tell the patient which team members will assist with the procedure.
Answer: B. Witness the patient's signature on the consent form.
Rationale: The nurse is responsible for witnessing the patient sign the consent form. The nurse
should confirm that the patient appears competent to give consent and that the patient
understands the procedure.
21. A nurse on a medical unit is preparing to discharge a patient to home. Which of the following
actions should the nurse take as part of the medication reconciliation process?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the patient's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the patient received while at the facility.
Answer: D. Compare prescriptions with medications the patient received while at the facility.
Rationale: When performing medication reconciliation, the nurse should create a current,
accurate list of every medication the patient is or should be taking. Part of the process is
comparing the medications the patient received at the facility with those the provider has
prescribed for the patient to take after discharge.
22. A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy.
The nurse should include in the teaching that this therapy might be contraindicated for which of
the following patients?
A. A patient who has a history of physical abuse
B. A patient who has a permanent pacemaker
C. A patient who has ulcerative colitis
D. A patient who has asthma
Answer: D. A patient who has asthma
Rationale: Some essential oils can cause bronchospasm; therefore, the nurse should consult the
patient's provider before using this therapy for a patient who has asthma.
23. A nurse is caring for a patient who has recently started using a behind-the-ear hearing aid.
Which of the following statements should the nurse identify as an indication that the patient
understands the use of this assistive device?
A. "This type of hearing aid does not allow for fine tuning of volume."
B. "I shouldn't have trouble keeping the hearing aid in place during exercise."
C. "I expect to hear a whistling sound when I first insert the hearing aid."
D. "I will be sure to remove my hearing aid before taking a shower."
Answer: D. "I will be sure to remove my hearing aid before taking a shower."
Rationale: Patients should remove any hearing devices before showering because exposure to
water can damage them.
24. A nurse is caring for a patient who is receiving pain medication through a patient-controlled
analgesia (PCA) pump. Which of the following actions should the nurse take?
A. Instruct the family to refrain from pushing the button for the patient while she is asleep.
B. Inform the patient that because she is on PCA, vital signs will be taken every 8 hr.
C. Teach the patient to avoid pushing the button until pain is above a 7 on a scale of 0 to 10.
D. Increase the basal rate and shorten the lock-out interval time if the patient's pain level is too
high.
Answer: A. Instruct the family to refrain from pushing the button for the patient while she is
asleep.
Rationale: The nurse should instruct family members not to activate the button for the patient
while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects
could still occur if the patient receives more medication than necessary to control pain.
25. A nurse is caring for a patient who is refusing a blood transfusion for religious reasons. The
patient's partner wants the patient to have the blood transfusion. Which of the following actions
should the nurse take?
A. Ask the patient to consider a direct donation.
B. Withhold the blood transfusion.
C. Request a consultation with the ethics committee.
D. Ask the patient's family to intervene.
Answer: B. Withhold the blood transfusion.
Rationale: The principle of autonomy ensures that a patient who is competent has the right to
refuse treatment.
26. A nurse is planning care for a patient who has tuberculosis. The nurse should use which of
the following pieces of personal protective equipment when providing care for the patient?
A. Gown
B. N95 respirator
C. Shoe covers
D. Surgical cap
Answer: B. N95 respirator
Rationale: The nurse should wear an N95 respirator when providing care for a patient who
requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.
27. Describe these sounds:
A. Narrowed arterial lumen
B. Distended jugular veins
C. Impaired ventricular contraction
D. Asynchronous closure of the aortic and pulmonic valves
Answer: A. Narrowed arterial lumen
Rationale: • Blowing sounds resulting from blood flowing through occluded or narrowed
arteries are known as a bruit.
• Distended jugular veins - Blood flowing through distended jugular veins does not produce a
sound.
• Impaired ventricular contraction - Impaired ventricular function produces extra heart sounds,
either S3 or S4. These sounds are best heard over the aortic area of the heart.
• Asynchronous closure of the aortic and pulmonic valves - Asynchronous closure of the aortic
and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds
during auscultation. This sound is best heard over the aortic area of the heart.
28. A middle adult patient 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. "Most people are happy when their children grow up and leave home."
B. "You should be proud that your children are becoming independent."
C. "Maybe you should consider why you are feeling useless."
D. "People in middle adulthood often find satisfaction in nurturing and guiding young people."
Answer: D. "People in middle adulthood often find satisfaction in nurturing and guiding young
people."
Rationale: 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 opportunities for mastering the developmental tasks of
this stage with the patient, such as volunteering and mentoring young people.
29. A nurse enters a patient's room and finds her on the floor. The patient's roommate reports that
the patient was trying to get out of bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this incident?
A. "Incident report completed."
B. "patient climbed over the side rails."
C. "patient found lying on floor."
D. "patient was trying to get out of bed."
Answer: C. "patient found lying on floor."
Rationale: The nurse should include documentation of information that is descriptive and
objective concerning what the nurse actually observed, without including any opinions or
judgments about motives or cause.
30. A nurse is caring for a patient who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
A. Wear sterile gloves when removing the old dressing.
B. Warm the irrigation solution to 40.5° C (105° F).
C. Cleanse the wound from the centre outward.
D. Use a 20-mL syringe to irrigate the wound.
Answer: C. Cleanse the wound from the centre outward.
Rationale: The nurse should clean the wound from the centre outward to prevent introduction of
microorganisms from the outer skin surface.
31. A nurse is preparing to delegate patient care tasks to an assistive personnel (AP). Which of
the following tasks should the nurse delegate?
A. Ambulating a patient who is postoperative
B. Inserting an indwelling urinary catheter for a patient
C. Demonstrating the use of an incentive spirometer to a patient
D. Confirming that a patient's pain has decreased after receiving an analgesic
Answer: A. Ambulating a patient who is postoperative
Rationale: Ambulating a patient is within the range of function of an AP. The nurse can delegate
tasks to the AP that do not require special skills, assessment, or teaching.
32. 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. Role play
B. Group discussions
C. Question-answer meetings
D. Practice sessions
Answer: D. Practice sessions
Rationale: Practice sessions require psychomotor skills when learning.
33. A nurse is caring for a patient who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer subcutaneously. Determine the correct order
of steps for this procedure.
A. Inject 5 units of air into the bottle of regular insulin.
B. Withdraw the correct dose of NPH insulin from the bottle.
C. Inject 10 units of air into the bottle of NPH insulin.
D. Withdraw the correct dose of regular insulin from the bottle.
Answer: A, C, D, B
Rationale: The nurse should first inject air into the vial of NPH insulin without touching the
needle to the solution. Next, the nurse should inject air into the vial of regular insulin and
withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle
into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should
follow these steps to prevent contaminating the regular insulin with NPH insulin.
34. A nurse is caring for a patient who reports difficulty falling asleep. Which of the following
recommendations should the nurse make?
A. "Drink a cup of hot cocoa before bedtime."
B. "Maintain a consistent time to wake up each day."
C. "Exercise 1 hour before going to bed."
D. "Watch a television program in bed before going to sleep."
Answer: B. "Maintain a consistent time to wake up each day."
Rationale: The patient should maintain a consistent time for waking up and going to sleep. This
helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it
over time. This will help promote sleep for the patient.
35. A nurse is caring for a patient who has terminal liver cancer. Which of the following
statements should the nurse identify as an indication that the patient is experiencing spiritual
distress?
A. "What could I have done to deserve this illness?"
B. "I blame medical science for not curing me."
C. "Where is my daughter at a time like this?"
D. "Will I ever begin to feel in charge of my life again?"
Answer: A. "What could I have done to deserve this illness?"
Rationale: The patient's terminal illness might prompt the patient to review their life and
question its meaning. A manifestation of the patient's spiritual distress is asking why this illness
is happening to them.
36. A nurse is assessing a patient who received an IV fluid bolus for hydration. Which of the
following findings should the nurse identify as an indication of fluid volume excess?
A. Hypotension
B. Weak, thready pulse
C. Slow capillary refill
D. Distended neck veins
Answer: D. Distended neck veins
Rationale: Indications of fluid volume excess include distended neck veins, edema, tachycardia,
crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.
37. A nurse is completing an admission assessment for a patient who reports vomiting and
diarrhoea for the past 3 days. Which of the following findings should the nurse expect?
A. Neck vein distension
B. Urine specific gravity of 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mm Hg
Answer: C. Rapid heart rate
Rationale: Tachycardia indicates fluid volume deficit, which is an expected finding for a patient
who has had vomiting and diarrhoea for 3 days.
38. A nurse is caring for a patient who reports pain. When documenting the quality of the
patient's pain on an initial pain assessment, the nurse should record which of the following
patient statements?
A. "I'm having mild pain."
B. "The pain is like a dull ache in my stomach."
C. "I notice that the pain gets worse after I eat."
D. "The pain makes me feel nauseous."
Answer: B. "The pain is like a dull ache in my stomach."
Rationale: The patient is describing the quality of the pain, which is how the pain feels in the
patient's own words.
39. A nurse is teaching a patient whose left leg is in a cast about using crutches. Which of the
following statements should the nurse identify as an indication that the patient understands the
teaching?
A. "When descending stairs, I will first shift my weight to my right leg."
B. "I should place my crutches 12 inches in front and to the side of each foot."
C. "As I sit down, I will hold one crutch in each hand."
D. "I will make sure the shoulder rests are snug against my armpits."
Answer: A. "When descending stairs, I will first shift my weight to my right leg."
Rationale: To descend stairs, the patient should first shift his body weight to his right, unaffected
leg.
40. A nurse is caring for a group of patients on a medical-surgical unit. In which of the following
situations does the nurse demonstrate the ethical principle of veracity?
A. A patient who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and
the nurse responds affirmatively.
B. A patient who has a prescription for a nasogastric tube refuses it, and the nurse complies with
the patient's wishes.
C. A patient who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does
not perform CPR despite requests from the patient's family.
D. A patient who is about to undergo a painful procedure receives pain medication 30 min before
the procedure that the nurse previously promised to administer.
Answer: A. A patient who is unaware of her recent cancer diagnosis asks the nurse if she has
cancer, and the nurse responds affirmatively.
Rationale: Following the ethical principle of veracity, the nurse must tell the truth at all times
and never deceive others.
41. A nurse is caring for a patient who has an indwelling urinary catheter. Which of the following
findings indicates that the catheter requires irrigation?
A. Urine has an unusual Odor.
B. Urine specific gravity is 1.035.
C. Bladder scan shows 525 mL of urine.
D. Urine is positive for ketones.
Answer: C. Bladder scan shows 525 mL of urine.
Rationale: A patient who has an indwelling urinary catheter should have a continuous urine flow
without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter
to resolve any existing blockage.
42. A nurse is providing discharge teaching for a patient who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the patient
and his family? (Select all that apply.)
A. Check the cord routinely for frays or tearing.
B. Keep the unit at least 1.2 m (4 feet ) away from a gas stove.
C. Consider purchasing a generator for power backup.
D. Observe for signs of hypoxia.
E. Select synthetic clothing and bedding.
Answer: A, C, D
Rationale: • Check the cord routinely for frays or tearing is correct. Oxygen concentrators
require electrical power. Safe use of this delivery system includes assessing the electrical
function of the device; therefore, the nurse should instruct the patient to routinely check the
condition of the cord.
• Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home
oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames,
such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.
• Consider purchasing a generator for power backup is correct. Loss of electricity prevents the
oxygen concentrator from functioning and could deprive the patient of necessary oxygen. The
nurse should also instruct the family to have the patient placed on their municipality's priority list
for restoring power after an outage occurs.
• Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and
report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and
respirations, pallor, and cyanosis. Even with supplemental oxygen, the patient's status can
worsen, resulting in the development of hypoxia.
• Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes
choosing clothing and bedding made from material that does not generate static electricity;
therefore, the nurse should instruct the patient to select materials made from cotton.
43. A nurse is caring for a patient who requires a 24-hr urine collection. Which of the following
statements by the patient indicates an understanding of the teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the test quickly."
Answer: C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
Rationale: For a 24-hr urine collection, the patient should discard the first voiding and save all
subsequent voiding’s.
44. A nurse is caring for a patient who is receiving fluid through a peripheral IV catheter. Which
of the following findings at the IV site should the nurse identify as indicating infiltration?
A. Purulent exudate
B. Warmth
C. Skin blanching
D. Bleeding
Answer: C. Skin blanching
Rationale: Skin blanching, edema, and coolness at the IV site indicate infiltration.
45. A charge nurse is discussing the responsibility of nurses caring for patients who have
Clostridium difficile infection. Which of the following information should the nurse include in
the teaching?
A. Assign the patient to a room with a negative airflow system.
B. Use alcohol-based hand sanitizer when leaving the patient's room.
C. Clean contaminated surfaces in the room with phenol solution.
D. Have family members wear a gown and gloves when visiting.
Answer: D. Have family members wear a gown and gloves when visiting.
Rationale: Nurses are responsible for ensuring that family members wear a gown and gloves to
prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
46. A nurse is preparing to transfer a patient 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. Rock the patient up to a standing position.
B. Pivot on the foot that is the farthest from the chair.
C. Assess the patient for orthostatic hypotension.
D. Apply a gait belt to the patient.
Answer: C. Assess the patient for orthostatic hypotension.
Rationale: The first action the nurse should take when using the nursing process is to assess the
patient. The nurse should determine the patient's risk for falling or fainting during the transfer by
assisting the patient to sit and dangle the feet on the side of the bed. The nurse should assess for
dizziness and a significant drop in blood pressure before assisting the patient to stand and
transfer into the chair.
47. A nurse is calculating a patient's fluid intake over the past 8 hr. Which of the following items
should the nurse plan to document on the patient's intake and output record as 120 mL of fluid?
A. 2 cups of soup
B. 1 quart of water
C. 8 oz of ice chips
D. 6 oz of tea
Answer: C. 8 oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when calculating fluid
intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid
water is equal to 120 mL of fluid.
48. A nurse is admitting a patient who has been having frequent tonic-clonic seizures. Which of
the following actions should the nurse add to the patient's plan of care?
A. Wrap blankets around all four sides of the bed.
B. Apply restraints during seizure activity.
C. Place the patient in a supine position during seizure activity.
D. Have a tongue depressor at the patient's bedside.
Answer: A. Wrap blankets around all four sides of the bed.
Rationale: The nurse should affix linens or blankets around the head, foot, and side rails of the
bed to pad them and prevent injury for a patient who has been having frequent tonic-clonic
seizures.
49. A home health nurse is completing an admission assessment of an older adult patient who has
their caregiver present. Which of the following findings should the nurse identify as a potential
indication of elder abuse?
A. The caregiver is the patient's financial power of attorney.
B. The patient is in a wheelchair with the wheels locked.
C. The patient reports receiving a full bath twice each week.
D. The caregiver insists on remaining in the room.
Answer: D. The caregiver insists on remaining in the room.
Rationale: A caregiver who refuses to leave the room during an admission assessment can be an
indication of potential mistreatment of the patient who is receiving care. The nurse should
evaluate the patient for additional signs of potential mistreatment throughout the admission
assessment.
50. A nurse is preparing to administer multiple medications to a patient who has an enteral
feeding tube. Which of the following actions should the nurse plan to take?
A. Dissolve each medication in 5 mL of sterile water.
B. Draw up medications together in the syringe.
C. Push the syringe plunger gently when feeling resistance.
D. Flush the tube with 15 mL of sterile water.
Answer: D. Flush the tube with 15 mL of sterile water.
Rationale: The nurse should flush the feeding tube with 15 to 30 mL of sterile water before
administration and between each medication. The nurse should flush the feeding tube with 30 to
60 mL of sterile water following the administration of the last medication.
51. A nurse is assessing an adult patient who has been immobile for the past 3 weeks. For which
of the following findings should the nurse intervene?
A. Erythema on pressure points
B. Lower-extremity pulse strength of 2+
C. Fluid intake of 3,000 mL per day
D. One bowel movement every other day
Answer: A. Erythema on pressure points
Rationale: Erythema on pressure points requires prompt relief of pressure and additional
measures to protect the skin from breakdown.
52. A patient who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse
confirms the presence of the fire, which of the following actions should the nurse take?
A. Activate the emergency fire alarm.
B. Extinguish the fire.
C. Evacuate the patient.
D. Confine the fire.
Answer: C. Evacuate the patient.
Rationale: According to the RACE mnemonic, the first action in response to a fire is to rescue
the patients, moving them to a safe area.
53. A nurse is caring for a patient who has a terminal diagnosis and whose health is declining.
The patient requests information about advance directives. Which of the following responses
should the nurse make?
A. "We can talk about advance directives, and I can also give you some brochures about them."
B. "You should set up a time to talk with your provider about that."
C. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling
a little better."
D. "Why do you want to discuss this without your partner here to plan this with you?"
Answer: A. "We can talk about advance directives, and I can also give you some brochures
about them."
Rationale: With this statement, the nurse offers to provide the information the patient needs in a
direct and simple way.
54. A nurse is caring for a patient who has limited mobility in his lower extremities. Which of the
following actions should the nurse take to prevent skin breakdown?
A. Place the patient in high-Fowler's position.
B. Increase the patient's intake of carbohydrates.
C. Massage reddened areas with unscented lotion.
D. Have the patient use a trapeze bar when changing position.
Answer: D. Have the patient use a trapeze bar when changing position.
Rationale: By using a trapeze bar to assist with repositioning and transferring, the patient avoids
the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for
pressure-injury development.
55. A nurse in an acute care facility is preparing a discharge summary for a patient who is
transferring to a long-term care facility. Which of the following documentation should the nurse
include?
A. Patient flow sheet
B. Acuity ratings
C. Current medications
D. Incident reports
Answer: C. Current medications
Rationale: The nurse should include the patient's medications in the discharge summary to
ensure patient safety and continuity of care.
56. A nurse is preparing a heparin infusion for a patient who was admitted to the facility with
deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride
250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round
the answer to the nearest whole number.)
Answer: 8 mL/hr
Follow these steps for the Ratio and Proportion method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL/hr
Step 2: What is the dose the nurse should administer? Dose to administer = Desired 800 units/hr
Step 3: What is the dose available? Dose available = Have 25,000 units
Step 4: Should the nurse convert the units of measurement?
No Step 5: What is the quantity of the dose available? 250 mL Step 6: Set up an equation and
solve for X. Have Desired = Quantity X
25,000 units800 units/hr = 250 mL X
mL X mL/hr = 8 mL/hr
Step 7: Round if necessary.
Step 8: Determine whether the amount to administer makes sense. If there are 25,000 units/250
mL and the prescription reads 800 units/hr, it makes sense to administer 8 mL/hr. The nurse
should set the infusion pump to administer 8 mL/hr.
57. A nurse is planning an educational program for a group of older adults at a senior living
centre. Which of the following recommendations should the nurse include?
A. "You should have an eye examination every 2 years."
B. "You should receive a tetanus booster every 5 years."
C. "You should receive a shingles vaccine when you are 70 years old."
D. "You should receive a pneumococcal vaccine when you are 65 years old."
Answer: D. "You should receive a pneumococcal vaccine when you are 65 years old."
Rationale: The nurse should instruct older adult patients to receive one of the two pneumococcal
vaccines when they are 65 years old. The vaccines can be given to patients who are 19 years of
age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes
mellitus, and alcohol disease, or to those who smoke cigarettes.
58. A nurse in a surgical suite notes documentation on a patient's medical record that he has a
latex allergy. In preparation for the patient's procedure, which of the following precautions
should the nurse take?
A. Ensure sterilization of non-disposable items with ethylene oxide.
B. Wrap monitoring cords with stockinette and tape them in place.
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
D. Wear hypoallergenic latex gloves that contain powder.
Answer: B. Wrap monitoring cords with stockinette and tape them in place.
Rationale: Many monitoring devices and cords contain latex. The nurse should prevent any
contact of these cords and devices with the patient's skin by covering them with a non-latex
barrier material, such as stockinette, and using non-latex tape to secure them.
59. A nurse is administering IV fluids to a patient. When monitoring for adverse effects, which of
the following assessments should the nurse identify as the priority?
A. Auscultate the lung sounds.
B. Measure urine output.
C. Monitor blood pressure readings.
D. Monitor electrolyte levels.
Answer: A. Auscultate the lung sounds.
Rationale: The priority assessment the nurse should make when using the airway, breathing,
circulation approach to patient care is auscultating lung sounds to monitor for fluid volume
excess, a complication of IV therapy. Manifestations of fluid volume excess include moist
crackles in lung fields, dyspnea, and shortness of breath.
60. A community health nurse is checking blood pressures for a group of patients at a community
health screening. Which of the following patients is at an increased risk for hypertension?
A. A patient who is 52 years old
B. A patient who smokes one pack of cigarettes each day
C. A patient who walks for 30 min every day
D. A patient who drinks one glass of wine three times per week
Answer: B. A patient who smokes one pack of cigarettes each day
Rationale: A patient who smokes one pack of cigarettes each day is at an increased risk for
hypertension.
61. A nurse is assessing an older patient during a home visit. Which of the following findings
should the nurse report to the nursing supervisor?
A. Brown macules distributed over the backs of both hands
B. Ecchymosis on the torso in various stages of healing
C. Flesh-coloured cutaneous tags in the axillary regions
D. Absence of skin tenting over the patient's sternal region
Answer: B. Ecchymosis on the torso in various stages of healing
Rationale: The nurse should identify ecchymosis in various stages of healing as a possible
indication of physical abuse. The nurse is required to report suspected elder maltreatment to a
supervisor for further investigation.
62. A nurse is working at a provider's office that uses various forms of electronic communication.
Which of the following actions should the nurse take to protect patient confidentiality?
A. Delete email correspondences once a patient's situation has been handled.
B. Ensure that the computer system does not use encryption or firewall services.
C. Verify that recipient contact information is correct before faxing information.
D. Avoid including a cover sheet when sending a facsimile.
Answer: C. Verify that recipient contact information is correct before faxing information.
Rationale: Before sending protected health information using a fax machine, the nurse should
verify the fax number of the individual receiving the information. This prevents individuals
without a legal right to the patient's records from having access to the information.
63. A nurse is talking with the family of a patient who is nearing the end of life. The nurse should
identify that agreeing to which of the following requests from the patient's family violates the
principle of justice?
A. "Give her a sedative so she will sleep and not wake up."
B. "We want her to have a feeding tube even though her living will say not to."
C. "Try to spend more time with her than with your other patients."
D. "We want you to tell her that she's getting better."
Answer: C. "Try to spend more time with her than with your other patients."
Rationale: When considering the ethical principle of justice, the nurse has a responsibility to act
fairly. The nurse should plan time with patients based on their individual needs, prioritizing the
most urgent patient needs.
64. A nurse is preparing to document a prescription from a provider. Which of the following
abbreviations should the nurse use?
A. "U" for "units"
B. "Q.D." for "daily"
C. "HS" for "bedtime"
D. "IV" for "intravenous"
Answer: D. IV for intravenous
Rationale: The nurse should use "IV" because it is an acceptable abbreviation to indicate an
intravenous route of administration.
65. A nurse has received change-of-shift report on a group of four patients. Which of the
following patients should the nurse see first?
A. A patient who requires teaching on self-administration of insulin
B. A patient who is scheduled for physical therapy and rates his pain as a 6 on a scale of 0 to 10
C. A patient who has a fractured leg following a motor-vehicle crash and is asking for details
about the crash
D. A patient who has an indwelling urinary catheter and a continuous IV infusion
Answer: B. A patient who is scheduled for physical therapy and rates his pain as a 6 on a scale
of 0 to 10
Rationale: When using Maslow's hierarchy of needs, the nurse should first assess this patient's
physiological needs for pain relief because the patient will be able to fully participate in physical
therapy following pain relief interventions.
