ATI Fundamental Practice Assessment A | Fundamentals Practice Assessment
A Exam Questions & Answers| 2025
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The
client's partner wants the client to have the blood transfusion. Which of the following actions
should the nurse take? - (answers)Withhold the blood transfusion.
Patients who are competent have the right to refuse
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the
following findings should the nurse identify as an indication of fluid volume excess? -
(answers)Distended neck veins
Symptoms of fluid volume excess include distended neck veins, edema, tachycardia, crackles in
the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy.
Which of the following interventions should the nurse include in the plan of care? -
(answers)Allow the adolescent to make decisions regarding his daily routine.
A nurse in a surgical suite notes documentation on a client's medical record that they have a latex
allergy. In preparation for the client's procedure, which of the following precautions should the
nurse take? - (answers)Wrap monitoring cords with stockinette and tape them in place
The nurse should prevent any contact of these cords and devices with the client's skin by
covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to
secure them.
,A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate? - (answers)Ambulating a client who is postoperative
teaching.
The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching
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 hr. Which of the following actions should the nurse take
next? - (answers)Notify the nursing manager
The greatest risk to the client is not receiving timely intervention for a deterioration in
physiological status; therefore, the next action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary care.
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The
client's family questions the nurse about the reasons for the transfer. Which of the following
responses made by the nurse is appropriate? - (answers)"Would you like it if we discussed the
transfer with your family member?"
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
Which of the following actions should the nurse take? - (answers)Subtract the amount of irrigant
used from the client's urine output.
A nurse is caring for a client who is having difficulty breathing. The client is supine and is
receiving supplemental oxygen via a nasal cannula.
Which of the following interventions should the nurse take first? - (answers)Assist the client to
an upright position
According to evidence-based practice the nurse should assist the client to an upright position.
This assists with chest expansion and increases the effectiveness of the existing supplemental
oxygen.
, 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? - (answers)Pad the client's wrist
before applying the restraints.
The use of restraints without padding can abrade the client's skin, resulting in client injury.
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's
dressing, they say, "Every time you change my bandage, it hurts so much." Which of the
following interventions is the nurse's priority action? - (answers)Administer pain medication 45
min before changing the client's dressing.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the
following statements should the nurse identify as an indication that the client understands the
preoperative teaching they received about pain management? - (answers)"It might help me to
listen to music while I'm lying in bed."
Listening to music is an effective nonpharmacological intervention for the management of mild
pain.
A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse
confirms the presence of the fire, which of the following actions should the nurse take next? -
(answers)Evacuate the client.
According to the RACE mnemonic, the first action in response to a fire is to rescue the clients,
moving them to a safe area.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client? -
(answers)Make sure the client wears a mask when outside her room if there is construction in the
area
A Exam Questions & Answers| 2025
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The
client's partner wants the client to have the blood transfusion. Which of the following actions
should the nurse take? - (answers)Withhold the blood transfusion.
Patients who are competent have the right to refuse
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the
following findings should the nurse identify as an indication of fluid volume excess? -
(answers)Distended neck veins
Symptoms of fluid volume excess include distended neck veins, edema, tachycardia, crackles in
the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy.
Which of the following interventions should the nurse include in the plan of care? -
(answers)Allow the adolescent to make decisions regarding his daily routine.
A nurse in a surgical suite notes documentation on a client's medical record that they have a latex
allergy. In preparation for the client's procedure, which of the following precautions should the
nurse take? - (answers)Wrap monitoring cords with stockinette and tape them in place
The nurse should prevent any contact of these cords and devices with the client's skin by
covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to
secure them.
,A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate? - (answers)Ambulating a client who is postoperative
teaching.
The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching
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 hr. Which of the following actions should the nurse take
next? - (answers)Notify the nursing manager
The greatest risk to the client is not receiving timely intervention for a deterioration in
physiological status; therefore, the next action the nurse should take is to activate the chain of
command to ensure that the client receives the necessary care.
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The
client's family questions the nurse about the reasons for the transfer. Which of the following
responses made by the nurse is appropriate? - (answers)"Would you like it if we discussed the
transfer with your family member?"
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
Which of the following actions should the nurse take? - (answers)Subtract the amount of irrigant
used from the client's urine output.
A nurse is caring for a client who is having difficulty breathing. The client is supine and is
receiving supplemental oxygen via a nasal cannula.
Which of the following interventions should the nurse take first? - (answers)Assist the client to
an upright position
According to evidence-based practice the nurse should assist the client to an upright position.
This assists with chest expansion and increases the effectiveness of the existing supplemental
oxygen.
, 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? - (answers)Pad the client's wrist
before applying the restraints.
The use of restraints without padding can abrade the client's skin, resulting in client injury.
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's
dressing, they say, "Every time you change my bandage, it hurts so much." Which of the
following interventions is the nurse's priority action? - (answers)Administer pain medication 45
min before changing the client's dressing.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the
following statements should the nurse identify as an indication that the client understands the
preoperative teaching they received about pain management? - (answers)"It might help me to
listen to music while I'm lying in bed."
Listening to music is an effective nonpharmacological intervention for the management of mild
pain.
A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse
confirms the presence of the fire, which of the following actions should the nurse take next? -
(answers)Evacuate the client.
According to the RACE mnemonic, the first action in response to a fire is to rescue the clients,
moving them to a safe area.
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell
transplant. Which of the following precautions should the nurse plan for this client? -
(answers)Make sure the client wears a mask when outside her room if there is construction in the
area
