ATI Fundamentals for Nursing Review
Module Edition 12.0 | Content Mastery
Series Test Bank & Rationales/instant pdf
download
Question 1
A nurse is assessing a client who reports dizziness when standing. Which finding
should the nurse recognize as consistent with orthostatic hypotension?
A. Blood pressure increases after standing
B. Heart rate decreases after standing
C. Blood pressure decreases after standing
D. Respiratory rate decreases after standing
Answer: _C. Blood pressure decreases after standing_
Rationale: Orthostatic hypotension is a significant decrease in blood pressure
when moving from lying or sitting to standing. It can cause dizziness, weakness,
and an increased risk for falls.
Question 2
A nurse is preparing to administer medication to a client. Which action is most
appropriate for verifying the client's identity?
A. Ask the client to state their room number
B. Check the client's name and date of birth against the medication record
C. Ask another client to identify the client
D. Verify the client's diagnosis
Answer: _B. Check the client's name and date of birth against the medication
record_
,Rationale: Using two approved identifiers, such as name and date of birth, helps
ensure that medications are administered to the correct client.
Question 3
A nurse is caring for a client with impaired mobility. Which intervention is most
effective for preventing pressure injuries?
A. Massage reddened areas
B. Reposition the client regularly
C. Restrict oral fluids
D. Place the client directly on a bony prominence
Answer: _B. Reposition the client regularly_
Rationale: Regular repositioning reduces prolonged pressure over bony
prominences and helps maintain tissue perfusion.
Question 4
A nurse is teaching a client about incentive spirometry following surgery. Which
instruction should the nurse provide?
A. Exhale forcefully into the device
B. Use the device once every 8 hr
C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly through the mouthpiece
Answer: _C. Inhale slowly and deeply through the mouthpiece_
Rationale: Incentive spirometry promotes deep inspiration and helps prevent
postoperative atelectasis. The client should inhale slowly and deeply through the
mouthpiece.
Question 5
A nurse is caring for a client who has dysphagia. Which intervention should the
nurse implement during meals?
A. Place the client in a supine position
B. Encourage the client to drink through a straw
,C. Position the client upright
D. Provide large bites of food
Answer: _C. Position the client upright_
Rationale: Upright positioning promotes safer swallowing and decreases the risk
of aspiration.
Question 6
A nurse is performing hand hygiene with soap and water. Which action is
appropriate?
A. Wash hands for approximately 5 seconds
B. Use friction over all hand surfaces
C. Rinse hands before applying soap
D. Dry hands using the same towel used by another client
Answer: _B. Use friction over all hand surfaces_
Rationale: Mechanical friction is essential for removing microorganisms from the
hands. The nurse should clean all surfaces thoroughly and dry with a clean
disposable towel.
Question 7
A nurse is assessing a client's pain. Which question best evaluates the location of
pain?
A. "How would you describe your pain?"
B. "What makes the pain worse?"
C. "Where exactly do you feel the pain?"
D. "When did the pain begin?"
Answer: _C. "Where exactly do you feel the pain?"_
Rationale: Asking where the client feels pain assesses its location. Pain assessment
should also address quality, severity, timing, and aggravating or relieving factors.
Question 8
, A nurse is caring for a client who has a prescription for oxygen therapy. Which
action is appropriate?
A. Apply petroleum jelly around the client's nares
B. Keep oxygen away from open flames
C. Allow smoking near the oxygen equipment
D. Use an electrical device with damaged wiring near oxygen equipment
Answer: _B. Keep oxygen away from open flames_
Rationale: Oxygen supports combustion. Clients receiving oxygen should be kept
away from flames, sparks, smoking, and other ignition sources.
Question 9
A nurse is changing a sterile dressing. Which action contaminates the sterile field?
A. Keeping sterile objects above waist level
B. Reaching across the sterile field
C. Opening the sterile package away from the body
D. Maintaining the sterile field within view
Answer: _B. Reaching across the sterile field_
Rationale: Reaching across a sterile field increases the risk of contamination.
Sterile objects should remain within the nurse's field of vision and should not be
exposed to contaminated areas.
Question 10
A client has a urinary catheter. Which intervention should the nurse use to reduce
the risk of infection?
A. Disconnect the drainage tubing routinely
B. Keep the drainage bag below bladder level
C. Place the drainage bag on the client's bed
D. Irrigate the catheter every shift without a prescription
Answer: _B. Keep the drainage bag below bladder level_
Module Edition 12.0 | Content Mastery
Series Test Bank & Rationales/instant pdf
download
Question 1
A nurse is assessing a client who reports dizziness when standing. Which finding
should the nurse recognize as consistent with orthostatic hypotension?
A. Blood pressure increases after standing
B. Heart rate decreases after standing
C. Blood pressure decreases after standing
D. Respiratory rate decreases after standing
Answer: _C. Blood pressure decreases after standing_
Rationale: Orthostatic hypotension is a significant decrease in blood pressure
when moving from lying or sitting to standing. It can cause dizziness, weakness,
and an increased risk for falls.
Question 2
A nurse is preparing to administer medication to a client. Which action is most
appropriate for verifying the client's identity?
A. Ask the client to state their room number
B. Check the client's name and date of birth against the medication record
C. Ask another client to identify the client
D. Verify the client's diagnosis
Answer: _B. Check the client's name and date of birth against the medication
record_
,Rationale: Using two approved identifiers, such as name and date of birth, helps
ensure that medications are administered to the correct client.
Question 3
A nurse is caring for a client with impaired mobility. Which intervention is most
effective for preventing pressure injuries?
A. Massage reddened areas
B. Reposition the client regularly
C. Restrict oral fluids
D. Place the client directly on a bony prominence
Answer: _B. Reposition the client regularly_
Rationale: Regular repositioning reduces prolonged pressure over bony
prominences and helps maintain tissue perfusion.
Question 4
A nurse is teaching a client about incentive spirometry following surgery. Which
instruction should the nurse provide?
A. Exhale forcefully into the device
B. Use the device once every 8 hr
C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly through the mouthpiece
Answer: _C. Inhale slowly and deeply through the mouthpiece_
Rationale: Incentive spirometry promotes deep inspiration and helps prevent
postoperative atelectasis. The client should inhale slowly and deeply through the
mouthpiece.
Question 5
A nurse is caring for a client who has dysphagia. Which intervention should the
nurse implement during meals?
A. Place the client in a supine position
B. Encourage the client to drink through a straw
,C. Position the client upright
D. Provide large bites of food
Answer: _C. Position the client upright_
Rationale: Upright positioning promotes safer swallowing and decreases the risk
of aspiration.
Question 6
A nurse is performing hand hygiene with soap and water. Which action is
appropriate?
A. Wash hands for approximately 5 seconds
B. Use friction over all hand surfaces
C. Rinse hands before applying soap
D. Dry hands using the same towel used by another client
Answer: _B. Use friction over all hand surfaces_
Rationale: Mechanical friction is essential for removing microorganisms from the
hands. The nurse should clean all surfaces thoroughly and dry with a clean
disposable towel.
Question 7
A nurse is assessing a client's pain. Which question best evaluates the location of
pain?
A. "How would you describe your pain?"
B. "What makes the pain worse?"
C. "Where exactly do you feel the pain?"
D. "When did the pain begin?"
Answer: _C. "Where exactly do you feel the pain?"_
Rationale: Asking where the client feels pain assesses its location. Pain assessment
should also address quality, severity, timing, and aggravating or relieving factors.
Question 8
, A nurse is caring for a client who has a prescription for oxygen therapy. Which
action is appropriate?
A. Apply petroleum jelly around the client's nares
B. Keep oxygen away from open flames
C. Allow smoking near the oxygen equipment
D. Use an electrical device with damaged wiring near oxygen equipment
Answer: _B. Keep oxygen away from open flames_
Rationale: Oxygen supports combustion. Clients receiving oxygen should be kept
away from flames, sparks, smoking, and other ignition sources.
Question 9
A nurse is changing a sterile dressing. Which action contaminates the sterile field?
A. Keeping sterile objects above waist level
B. Reaching across the sterile field
C. Opening the sterile package away from the body
D. Maintaining the sterile field within view
Answer: _B. Reaching across the sterile field_
Rationale: Reaching across a sterile field increases the risk of contamination.
Sterile objects should remain within the nurse's field of vision and should not be
exposed to contaminated areas.
Question 10
A client has a urinary catheter. Which intervention should the nurse use to reduce
the risk of infection?
A. Disconnect the drainage tubing routinely
B. Keep the drainage bag below bladder level
C. Place the drainage bag on the client's bed
D. Irrigate the catheter every shift without a prescription
Answer: _B. Keep the drainage bag below bladder level_
