ATI: Nurse Logic 2.0: Nursing Concepts
(Advance Test) With Answers And
Rationales
1. A nurse working in a provider's office is reinforcing
teaching with a client who is 14 weeks of gestation. The
nurse should instruct the client to immediately notify the
provider if she experiences which of the following?
A) Facial edema
B) Urinary frequency
C) Acid indigestion
D) Breast leakage
Correct Answer: A
Rationale: Facial edema is an indication of pregnancy-
induced hypertension (preeclampsia) and should be
reported immediately to the provider. Urinary frequency,
acid indigestion, and breast leakage are expected findings
during pregnancy.
2. A nurse working in a hospice facility is talking to a client's
son who is distressed because his mother cries frequently
and says she wants to die. Which of the following responses
by the nurse is appropriate?
A) "I know this must be difficult, but your mother will calm
down soon."
,B) "Let's discuss some strategies you can use when this
happens again."
C) "Individuals near death are ready to let go toward the
end."
D) "Have you determined why she is crying and saying she
is ready to die?"
Correct Answer: B
Rationale: This response offers to provide information,
which can reduce anxiety and enhance decision-making. It
creates a safe and secure environment, fosters trust and
respect, and is appropriate therapeutic communication.
3. A nurse is caring for a client who has a urinary tract
infection and is prescribed ciprofloxacin (Cipro). The client
exhibits urticaria and angioedema following administration
of the medication. Which of the following is the first action
the nurse should take?
A) Administer epinephrine (Adrenaline)
B) Elevate the lower extremities
C) Determine respiratory status
D) Apply oxygen via non-rebreather mask
Correct Answer: C
Rationale: The client is experiencing angioedema, indicating
the possibility of an anaphylactic reaction, which is life-
threatening. Using the ABC priority setting framework, the
nurse should first determine the client's respiratory status.
,4. A nurse is caring for a child who is 24 hr postoperative
following a supratentorial craniotomy. The nurse should
maintain the child in which of the following positions?
A) Prone with head of the bed flat
B) Dorsal recumbent with head of the bed elevated to 15°
C) Supine with head of the bed elevated to 30°
D) Side-lying with head of the bed elevated to 45°
Correct Answer: C
Rationale: Following a supratentorial craniotomy, the client
should be positioned supine with the head of the bed
elevated to 30° to facilitate drainage of cerebrospinal fluid
and prevent hemorrhage by reducing blood flow to the
brain.
5. A nurse has assigned four tasks to an assistive personnel
(AP). Which of the following should the nurse instruct the AP
to perform first?
A) Take an ABG specimen to the laboratory
B) Transport a client to the radiology department for an x-
ray
C) Obtain a clean catch urine sample from a newly admitted
client
D) Pass fresh water to clients
Correct Answer: A
Rationale: ABG samples are kept on ice and should be
transported immediately to the laboratory or the specimen
, will deteriorate, causing inaccurate results. This is the task
the nurse should instruct the AP to perform first.
6. A nurse is caring for a client who has an acid-base
imbalance. For which of the following manifestations is
metabolic alkalosis a possible complication?
A) Hyperkalemia
B) Severe diarrhea
C) Atelectasis
D) Excessive vomiting
Correct Answer: D
Rationale: Metabolic alkalosis is a potential complication of
excessive vomiting because of the loss of acid (hydrochloric
acid) from the body. Severe diarrhea causes metabolic
acidosis.
7. A nurse is caring for a client who had a cerebrovascular
accident 2 days ago. Which of the following is the first sign
of increased intracranial pressure (ICP)?
A) Pupil dilation
B) Ataxia
C) Lethargy
D) Bradycardia
Correct Answer: C
Rationale: Lethargy occurs when pressure is placed on the
reticular activating system within the brainstem. Along with
(Advance Test) With Answers And
Rationales
1. A nurse working in a provider's office is reinforcing
teaching with a client who is 14 weeks of gestation. The
nurse should instruct the client to immediately notify the
provider if she experiences which of the following?
A) Facial edema
B) Urinary frequency
C) Acid indigestion
D) Breast leakage
Correct Answer: A
Rationale: Facial edema is an indication of pregnancy-
induced hypertension (preeclampsia) and should be
reported immediately to the provider. Urinary frequency,
acid indigestion, and breast leakage are expected findings
during pregnancy.
2. A nurse working in a hospice facility is talking to a client's
son who is distressed because his mother cries frequently
and says she wants to die. Which of the following responses
by the nurse is appropriate?
A) "I know this must be difficult, but your mother will calm
down soon."
,B) "Let's discuss some strategies you can use when this
happens again."
C) "Individuals near death are ready to let go toward the
end."
D) "Have you determined why she is crying and saying she
is ready to die?"
Correct Answer: B
Rationale: This response offers to provide information,
which can reduce anxiety and enhance decision-making. It
creates a safe and secure environment, fosters trust and
respect, and is appropriate therapeutic communication.
3. A nurse is caring for a client who has a urinary tract
infection and is prescribed ciprofloxacin (Cipro). The client
exhibits urticaria and angioedema following administration
of the medication. Which of the following is the first action
the nurse should take?
A) Administer epinephrine (Adrenaline)
B) Elevate the lower extremities
C) Determine respiratory status
D) Apply oxygen via non-rebreather mask
Correct Answer: C
Rationale: The client is experiencing angioedema, indicating
the possibility of an anaphylactic reaction, which is life-
threatening. Using the ABC priority setting framework, the
nurse should first determine the client's respiratory status.
,4. A nurse is caring for a child who is 24 hr postoperative
following a supratentorial craniotomy. The nurse should
maintain the child in which of the following positions?
A) Prone with head of the bed flat
B) Dorsal recumbent with head of the bed elevated to 15°
C) Supine with head of the bed elevated to 30°
D) Side-lying with head of the bed elevated to 45°
Correct Answer: C
Rationale: Following a supratentorial craniotomy, the client
should be positioned supine with the head of the bed
elevated to 30° to facilitate drainage of cerebrospinal fluid
and prevent hemorrhage by reducing blood flow to the
brain.
5. A nurse has assigned four tasks to an assistive personnel
(AP). Which of the following should the nurse instruct the AP
to perform first?
A) Take an ABG specimen to the laboratory
B) Transport a client to the radiology department for an x-
ray
C) Obtain a clean catch urine sample from a newly admitted
client
D) Pass fresh water to clients
Correct Answer: A
Rationale: ABG samples are kept on ice and should be
transported immediately to the laboratory or the specimen
, will deteriorate, causing inaccurate results. This is the task
the nurse should instruct the AP to perform first.
6. A nurse is caring for a client who has an acid-base
imbalance. For which of the following manifestations is
metabolic alkalosis a possible complication?
A) Hyperkalemia
B) Severe diarrhea
C) Atelectasis
D) Excessive vomiting
Correct Answer: D
Rationale: Metabolic alkalosis is a potential complication of
excessive vomiting because of the loss of acid (hydrochloric
acid) from the body. Severe diarrhea causes metabolic
acidosis.
7. A nurse is caring for a client who had a cerebrovascular
accident 2 days ago. Which of the following is the first sign
of increased intracranial pressure (ICP)?
A) Pupil dilation
B) Ataxia
C) Lethargy
D) Bradycardia
Correct Answer: C
Rationale: Lethargy occurs when pressure is placed on the
reticular activating system within the brainstem. Along with
