Crush Your ATI 2025 Fundamentals Proctored
RETAKE Exam: Ultimate Retake Guide EXAM
QUESTIONS AND WELL ELABORATED ANSWERS (3
VERSIONS)
a nurse is caring for a client who is postoperative and is exhibiting
signs of hemorrhagic shock. the nurse notifies the surgeon, who tells
the nurse to continue to measure the client's vital signs every 15 min
and to report back in 1 hour
-which of the following actions should the nurse take next? - CORRECT
ANSWER -notify the nursing manager
a nurse is preparing a change of shift report
-which of the following tools or documents should the nurse use to
communicate continuity of care? - CORRECT ANSWER -situation,
background, assessment, recommendation (SBAR)
a nurse is planning to insert a peripheral IV catheter for an older adult
client
-which of the following actions should the nurse plan to take? -
CORRECT ANSWER -place the client's arm in a dependent position
a nurse is caring for a client who is postoperative and refuses to use
an incentive spirometer following major abdominal surgery
-which of the following actions is the nurse's priority? - CORRECT
ANSWER -determine the reasons why the client is refusing to use the
incentive spirometer
a nurse manager is preparing to review medication documentation
with a group of newly licensed nurses
-which of the following statements should the nurse manager plan to
include in the teaching? - CORRECT ANSWER -"use the complete
name of the medication magnesium sulfate"
,a nurse is responding to a call light and finds a client lying on the
bathroom floor
-which of the following actions should the nurse take first? - CORRECT
ANSWER -check the client for injuries
a nurse on a medical surgical unit is caring for a client who has a new
prescription for wrist restraints
-which of the following actions should the nurse take? - CORRECT
ANSWER -pad the client's wrist before applying the restraints
a home health nurse is performing a follow up visit for a client who has
a gastrostomy tube through which they receive intermittent feedings
and medications. the client has recently developed diarrhea
-which of the following findings should the nurse identify as a possible
cause of the diarrhea? - CORRECT ANSWER -the client's caregiver
washes out the feeding bag with warm water once every 24 hrs
a nurse is caring for a client who is postoperative. when the nurse
prepares to change her dressing, she says "Every time you change my
bandage it hurts so much"
-which of the following interventions is the nurse's priority action? -
CORRECT ANSWER -administer pain medication 45 min before
changing the client's dressing
a nurse is caring for a client who has diarrhea due to shigella
-which of the following precautions should the nurse implement for
this client? - CORRECT ANSWER -wear a gown when caring for the
client
a nurse is administering 1 L of 0.9% sodium chloride to a client who is
postoperative and has fluid volume deficit
-which of the following changes should the nurse identify as an
indication that the treatment was successful? - CORRECT ANSWER -
decrease in heart rate
a nurse is preparing to administer an injection of an opioid medication
to a client. the nurse draws out 1 mL of the medication from a 2 mL
vial
,-which of the following actions should the nurse take? - CORRECT
ANSWER -ask another nurse to observe the medication wastage
a nurse is caring for a client who has a sodium level of 125 mEq/L
-which of the following findings should the nurse expect? - CORRECT
ANSWER -abdominal cramping
a nurse is preparing an education program for staff about advocacy
-which of the following information should the nurse include? -
CORRECT ANSWER -advocacy ensures clients' safety, health and
rights
a nurse is caring for a client who has an aggressive form of prostate
cancer. the provider briefly discusses treatment options and leaves
the client's room. when the nurse asks if the client would like to
discuss any concerns, the client declines
-which of the following statements should the nurse make? - CORRECT
ANSWER -"I am available to talk if you should change your mind"
a nurse is assessing a client's readiness to learn about insulin self
administration
-which of the following statements should the nurse identify as an
indication that the client is ready to learn? - CORRECT ANSWER -"I
can concentrate best in the morning"
a nurse is caring for a client who asks about the purpose of advance
directive
-which of the following statements should the nurse make? - CORRECT
ANSWER -"they indicate the form of treatment a client is willing to
accept in the event of a serious illness"
a nurse is assessing four adult clients
-which of the following physical assessment techniques should the
nurse use? - CORRECT ANSWER -ensure the bladder of the blood
pressure cuff surrounds 80% of the client's arm
A client who is postoperative is verbalizing pain as a 2 on a pain scale
of 0-10
, -which of the following statements should the nurse identify as an
indication that the client understands the preoperative teaching she
received about pain management? - CORRECT ANSWER -"it might
help me to listen to music while I'm lying in bed"
What do nurses use when preparing change-of-shift report? - CORRECT
ANSWER Standard handoff communication tools, such as
Introduction, Situation, Background, Assessment, Recommendation
(ISBAR) to facilitate transfers and discharges.
When should discharge planning begin? - CORRECT ANSWER On
admission with every patient.
Discharge documentation should include - CORRECT ANSWER Type
of discharge, date & time of discharge, who went with the client &
transportation, where the client went, summary of clients current
condition at discharge, description of any unresolved difficulties and
disposition of valuables, medications brought from home &
prescriptions.
Documentation & abbreviations and symbols - CORRECT ANSWER
Being accurate & concise is an important element of documentation.
Only abbreviations & symbols approved by The Joint Commission and
the facility are acceptable.
A nurse is discussing the HIPPA privacy rule with nurses during new
employee orientation. Which of the following information should the
nurse include? - CORRECT ANSWER Family members should provide
a code prior to receiving client health information, communication of a
client can occur at the nurse's station, a client can request a hard
copy of their records and a nurses may photocopy a client's medical
record for transfer to another facility.
A nurse is receiving a providers prescription for morphine by telephone
for a client who is reporting moderate to severe pain. What are the
appropriate nursing actions? - CORRECT ANSWER Repeat the details
of the prescription back to the provider, have another nurse listen to
RETAKE Exam: Ultimate Retake Guide EXAM
QUESTIONS AND WELL ELABORATED ANSWERS (3
VERSIONS)
a nurse is caring for a client who is postoperative and is exhibiting
signs of hemorrhagic shock. the nurse notifies the surgeon, who tells
the nurse to continue to measure the client's vital signs every 15 min
and to report back in 1 hour
-which of the following actions should the nurse take next? - CORRECT
ANSWER -notify the nursing manager
a nurse is preparing a change of shift report
-which of the following tools or documents should the nurse use to
communicate continuity of care? - CORRECT ANSWER -situation,
background, assessment, recommendation (SBAR)
a nurse is planning to insert a peripheral IV catheter for an older adult
client
-which of the following actions should the nurse plan to take? -
CORRECT ANSWER -place the client's arm in a dependent position
a nurse is caring for a client who is postoperative and refuses to use
an incentive spirometer following major abdominal surgery
-which of the following actions is the nurse's priority? - CORRECT
ANSWER -determine the reasons why the client is refusing to use the
incentive spirometer
a nurse manager is preparing to review medication documentation
with a group of newly licensed nurses
-which of the following statements should the nurse manager plan to
include in the teaching? - CORRECT ANSWER -"use the complete
name of the medication magnesium sulfate"
,a nurse is responding to a call light and finds a client lying on the
bathroom floor
-which of the following actions should the nurse take first? - CORRECT
ANSWER -check the client for injuries
a nurse on a medical surgical unit is caring for a client who has a new
prescription for wrist restraints
-which of the following actions should the nurse take? - CORRECT
ANSWER -pad the client's wrist before applying the restraints
a home health nurse is performing a follow up visit for a client who has
a gastrostomy tube through which they receive intermittent feedings
and medications. the client has recently developed diarrhea
-which of the following findings should the nurse identify as a possible
cause of the diarrhea? - CORRECT ANSWER -the client's caregiver
washes out the feeding bag with warm water once every 24 hrs
a nurse is caring for a client who is postoperative. when the nurse
prepares to change her dressing, she says "Every time you change my
bandage it hurts so much"
-which of the following interventions is the nurse's priority action? -
CORRECT ANSWER -administer pain medication 45 min before
changing the client's dressing
a nurse is caring for a client who has diarrhea due to shigella
-which of the following precautions should the nurse implement for
this client? - CORRECT ANSWER -wear a gown when caring for the
client
a nurse is administering 1 L of 0.9% sodium chloride to a client who is
postoperative and has fluid volume deficit
-which of the following changes should the nurse identify as an
indication that the treatment was successful? - CORRECT ANSWER -
decrease in heart rate
a nurse is preparing to administer an injection of an opioid medication
to a client. the nurse draws out 1 mL of the medication from a 2 mL
vial
,-which of the following actions should the nurse take? - CORRECT
ANSWER -ask another nurse to observe the medication wastage
a nurse is caring for a client who has a sodium level of 125 mEq/L
-which of the following findings should the nurse expect? - CORRECT
ANSWER -abdominal cramping
a nurse is preparing an education program for staff about advocacy
-which of the following information should the nurse include? -
CORRECT ANSWER -advocacy ensures clients' safety, health and
rights
a nurse is caring for a client who has an aggressive form of prostate
cancer. the provider briefly discusses treatment options and leaves
the client's room. when the nurse asks if the client would like to
discuss any concerns, the client declines
-which of the following statements should the nurse make? - CORRECT
ANSWER -"I am available to talk if you should change your mind"
a nurse is assessing a client's readiness to learn about insulin self
administration
-which of the following statements should the nurse identify as an
indication that the client is ready to learn? - CORRECT ANSWER -"I
can concentrate best in the morning"
a nurse is caring for a client who asks about the purpose of advance
directive
-which of the following statements should the nurse make? - CORRECT
ANSWER -"they indicate the form of treatment a client is willing to
accept in the event of a serious illness"
a nurse is assessing four adult clients
-which of the following physical assessment techniques should the
nurse use? - CORRECT ANSWER -ensure the bladder of the blood
pressure cuff surrounds 80% of the client's arm
A client who is postoperative is verbalizing pain as a 2 on a pain scale
of 0-10
, -which of the following statements should the nurse identify as an
indication that the client understands the preoperative teaching she
received about pain management? - CORRECT ANSWER -"it might
help me to listen to music while I'm lying in bed"
What do nurses use when preparing change-of-shift report? - CORRECT
ANSWER Standard handoff communication tools, such as
Introduction, Situation, Background, Assessment, Recommendation
(ISBAR) to facilitate transfers and discharges.
When should discharge planning begin? - CORRECT ANSWER On
admission with every patient.
Discharge documentation should include - CORRECT ANSWER Type
of discharge, date & time of discharge, who went with the client &
transportation, where the client went, summary of clients current
condition at discharge, description of any unresolved difficulties and
disposition of valuables, medications brought from home &
prescriptions.
Documentation & abbreviations and symbols - CORRECT ANSWER
Being accurate & concise is an important element of documentation.
Only abbreviations & symbols approved by The Joint Commission and
the facility are acceptable.
A nurse is discussing the HIPPA privacy rule with nurses during new
employee orientation. Which of the following information should the
nurse include? - CORRECT ANSWER Family members should provide
a code prior to receiving client health information, communication of a
client can occur at the nurse's station, a client can request a hard
copy of their records and a nurses may photocopy a client's medical
record for transfer to another facility.
A nurse is receiving a providers prescription for morphine by telephone
for a client who is reporting moderate to severe pain. What are the
appropriate nursing actions? - CORRECT ANSWER Repeat the details
of the prescription back to the provider, have another nurse listen to
