ATI CBC Level 1 Practice A Test With
Rationales
Nurse assessing preschooler with UTI, which of the following findings should the nurse expect? -
CORRECT ANSWER Abdominal Pain
Rationale: also included constipation, dysuria, foul-smelling urine, and fever
Nurse is counseling a client who has a family history of colorectal cancer about nutrition
management to help prevent GI cancers. Which image indicates what the nurse should encourage
the client to include liberally in diet? - CORRECT ANSWER Fruit
Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day per female,
consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat), NOT
white bread (refined grain products)
A nurse is preparing to extinguish a small fire in clients room. Which of the following actions should
the nurse take when using the fire extinguisher? - CORRECT ANSWER Slide the pin on top of the fire
extinguisher straight out
Rationale: This allows use of the extinguisher, should aim at base of the fire, squeeze the handles,
sweep from side to side to expel it evenly (not circular)
A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's meal
tray? - CORRECT ANSWER Oatmeal with raisins
Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can give scrambled eggs, corn (corn flake
cereal), and orange juice. This disease can cause diarrhea, weight loss, abd pain, and fatigue when
consuming gluten.
A nurse at a providers office is counseling a client who reports insomnia. Which of the following
statements should the nurse make to include the clients preferences into a sleep promotion plan? -
CORRECT ANSWER "Sleep in the location of your home where you feel you rest best"
Rationale: encourage client to sleep where they sleep best (couch, bed, chair), DO NOT consume
alcohol in late afternoon or evening (it can inhibit sleep, if needed consume earlier in the day. DO
NOT turn on TV, light and noise at bedtime can reduce sleep, also Maintain regular sleep and wake
times to improve sleep patterns
A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks the
preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the
nurse expect? - CORRECT ANSWER "It's wrong because my dad said I can't kick her"
,Rationale: The nurse should expect the preschooler to be motivated to choose right from wrong
because of the rules taught to him by his parents. He will not yet choose right from wrong bc of how
his actions affect others (more focused on how will affect himself)
A nurse in a long term care facility is admitting a new client following a brief stay in acute care. In
adherence with the joint commission national patient safety goals regarding med admin, which of
the following actions should the nurse take? - CORRECT ANSWER Compare a list of the clients current
medications with the ones he will take in long-term care.
Rationale: this includes maintaining and communicating Accurate client medication information.
A nurse is caring for a client who is 2 days post op following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the
following actions should the nurse take to treat the clients pain? - CORRECT ANSWER Administer a
beta-blocking medication to the client
Rationale: These have been shown to relieve the phantom limb pain manifestations of dull and
burning type pain. The nurse should position client on a firm mattress to prevent hip flexor
contractures. Might be able to use heat, ultrasound therapy, or transcutaneous electrical nerve
stimulation for PLP. Bandage should be secured snugly to reduce edema and promote limb
shrinkage. Loosening it will not help PLP.
A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks,
which of the following statements by the parent indicates an understanding of the teaching? -
CORRECT ANSWER "I can give her watermelon pieces after I remove the seeds"
Rationale: can easily choke on seeds or pits. Can easily choke on grapes (peeling them don't help),
have to cut grapes into small pieces before offering them to a toddler, can easily choke on popcorn
bc of its tendency to swell and not dissolve (not putting salt or butter helps nutritionally but not for
choking), can easily choke on hot dog slices (slicing thinly doesn't help)
A nurse is searching electronic databases for clinical research about behavioral indicators of pain in
an infant. Which of the following online sources should the nurse select to research this infant care
issue? - CORRECT ANSWER Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Rationale: use to locate clinical research about health-related client care issues.
A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions
should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? - CORRECT
ANSWER Delay the clients meal time if he is fatigued
Rationale: To promote safety, the nurse should encourage the client to rest prior to meal time. If
fatigued, give client time to rest. Should instruct to tilt head forward, avoid using a syringe to force
, fluids into their mouth, nurse should attempt to eliminate distractions and disruptions while PT is
eating (TV)
A nurse in a long term care facility is performing a fall risk assessment on a newly admitted client
using the timed up and go (TUG) test. The client reports using a tripod cane for ambulation. Which of
the following actions should the nurse take when using this test? - CORRECT ANSWER Observe the
client ambulating a distance of 3 m (10 feet) during the TUG test
Rationale: instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair,
and sit down. Observe clients ability and use stopwatch. If longer than 14 seconds then at increased
risk for falls. Use assistive aid if have one. Nurse avoid assisting them to stand. Client should avoid
using the arms of the chair for assistance when standing.
A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is
accompanied by his 16 year old mother and his maternal grandfather. Which of the following actions
should the nurse take when assisting with informed consent? - CORRECT ANSWER Witness consent
obtained from the infants mother.
Rationale: The nurse should assist in obtaining informed consent from the mother by witnessing her
signature. A minor even if unemancipated can provide consent for her infant. They can also legally
provide informed consent for STI tx, substance use tx, and care related to pregnancy in some states.
Use the grandparent if legal guardian or if parent is unavailable. Use court if parent is not acting in
child's best interest.
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
- CORRECT ANSWER Perform hand hygiene before touching the IV tubing.
Rationale: hand hygiene before touching any part of the infusion system or the client to reduce the
risk of infection. Change bags of IV solution every 24 hr, use antimicrobial agents (alcohol, povidone-
iodine, or chlorhexidine) NOT hydrogen peroxide for sure care, check IV site every 4 hr for
manifestations of infection at the insertion site
A nurse is caring for an adolescent client who is in critical condition following a MVA in which he was
the passenger. The clients parent shouts at the nurse, asking why her son is dying instead of the
driver. Which of the following actions should the nurse take to provide emotional support to the
parent? - CORRECT ANSWER Inform the parent that anger is a natural response when dealing with
loss.
Rationale: Nurse should identify that the parent is in the anger stage of grief. Parent should talk to
nurse or grief counselor. Encourage parent to remain in the facility to talk about her feelings and
offer a safe environment. Offer clergy member, don't get clergy without asking first.
Rationales
Nurse assessing preschooler with UTI, which of the following findings should the nurse expect? -
CORRECT ANSWER Abdominal Pain
Rationale: also included constipation, dysuria, foul-smelling urine, and fever
Nurse is counseling a client who has a family history of colorectal cancer about nutrition
management to help prevent GI cancers. Which image indicates what the nurse should encourage
the client to include liberally in diet? - CORRECT ANSWER Fruit
Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day per female,
consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat), NOT
white bread (refined grain products)
A nurse is preparing to extinguish a small fire in clients room. Which of the following actions should
the nurse take when using the fire extinguisher? - CORRECT ANSWER Slide the pin on top of the fire
extinguisher straight out
Rationale: This allows use of the extinguisher, should aim at base of the fire, squeeze the handles,
sweep from side to side to expel it evenly (not circular)
A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's meal
tray? - CORRECT ANSWER Oatmeal with raisins
Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can give scrambled eggs, corn (corn flake
cereal), and orange juice. This disease can cause diarrhea, weight loss, abd pain, and fatigue when
consuming gluten.
A nurse at a providers office is counseling a client who reports insomnia. Which of the following
statements should the nurse make to include the clients preferences into a sleep promotion plan? -
CORRECT ANSWER "Sleep in the location of your home where you feel you rest best"
Rationale: encourage client to sleep where they sleep best (couch, bed, chair), DO NOT consume
alcohol in late afternoon or evening (it can inhibit sleep, if needed consume earlier in the day. DO
NOT turn on TV, light and noise at bedtime can reduce sleep, also Maintain regular sleep and wake
times to improve sleep patterns
A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks the
preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the
nurse expect? - CORRECT ANSWER "It's wrong because my dad said I can't kick her"
,Rationale: The nurse should expect the preschooler to be motivated to choose right from wrong
because of the rules taught to him by his parents. He will not yet choose right from wrong bc of how
his actions affect others (more focused on how will affect himself)
A nurse in a long term care facility is admitting a new client following a brief stay in acute care. In
adherence with the joint commission national patient safety goals regarding med admin, which of
the following actions should the nurse take? - CORRECT ANSWER Compare a list of the clients current
medications with the ones he will take in long-term care.
Rationale: this includes maintaining and communicating Accurate client medication information.
A nurse is caring for a client who is 2 days post op following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the
following actions should the nurse take to treat the clients pain? - CORRECT ANSWER Administer a
beta-blocking medication to the client
Rationale: These have been shown to relieve the phantom limb pain manifestations of dull and
burning type pain. The nurse should position client on a firm mattress to prevent hip flexor
contractures. Might be able to use heat, ultrasound therapy, or transcutaneous electrical nerve
stimulation for PLP. Bandage should be secured snugly to reduce edema and promote limb
shrinkage. Loosening it will not help PLP.
A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks,
which of the following statements by the parent indicates an understanding of the teaching? -
CORRECT ANSWER "I can give her watermelon pieces after I remove the seeds"
Rationale: can easily choke on seeds or pits. Can easily choke on grapes (peeling them don't help),
have to cut grapes into small pieces before offering them to a toddler, can easily choke on popcorn
bc of its tendency to swell and not dissolve (not putting salt or butter helps nutritionally but not for
choking), can easily choke on hot dog slices (slicing thinly doesn't help)
A nurse is searching electronic databases for clinical research about behavioral indicators of pain in
an infant. Which of the following online sources should the nurse select to research this infant care
issue? - CORRECT ANSWER Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Rationale: use to locate clinical research about health-related client care issues.
A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions
should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? - CORRECT
ANSWER Delay the clients meal time if he is fatigued
Rationale: To promote safety, the nurse should encourage the client to rest prior to meal time. If
fatigued, give client time to rest. Should instruct to tilt head forward, avoid using a syringe to force
, fluids into their mouth, nurse should attempt to eliminate distractions and disruptions while PT is
eating (TV)
A nurse in a long term care facility is performing a fall risk assessment on a newly admitted client
using the timed up and go (TUG) test. The client reports using a tripod cane for ambulation. Which of
the following actions should the nurse take when using this test? - CORRECT ANSWER Observe the
client ambulating a distance of 3 m (10 feet) during the TUG test
Rationale: instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair,
and sit down. Observe clients ability and use stopwatch. If longer than 14 seconds then at increased
risk for falls. Use assistive aid if have one. Nurse avoid assisting them to stand. Client should avoid
using the arms of the chair for assistance when standing.
A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is
accompanied by his 16 year old mother and his maternal grandfather. Which of the following actions
should the nurse take when assisting with informed consent? - CORRECT ANSWER Witness consent
obtained from the infants mother.
Rationale: The nurse should assist in obtaining informed consent from the mother by witnessing her
signature. A minor even if unemancipated can provide consent for her infant. They can also legally
provide informed consent for STI tx, substance use tx, and care related to pregnancy in some states.
Use the grandparent if legal guardian or if parent is unavailable. Use court if parent is not acting in
child's best interest.
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
- CORRECT ANSWER Perform hand hygiene before touching the IV tubing.
Rationale: hand hygiene before touching any part of the infusion system or the client to reduce the
risk of infection. Change bags of IV solution every 24 hr, use antimicrobial agents (alcohol, povidone-
iodine, or chlorhexidine) NOT hydrogen peroxide for sure care, check IV site every 4 hr for
manifestations of infection at the insertion site
A nurse is caring for an adolescent client who is in critical condition following a MVA in which he was
the passenger. The clients parent shouts at the nurse, asking why her son is dying instead of the
driver. Which of the following actions should the nurse take to provide emotional support to the
parent? - CORRECT ANSWER Inform the parent that anger is a natural response when dealing with
loss.
Rationale: Nurse should identify that the parent is in the anger stage of grief. Parent should talk to
nurse or grief counselor. Encourage parent to remain in the facility to talk about her feelings and
offer a safe environment. Offer clergy member, don't get clergy without asking first.
