ATI fundamentals practice A
A client who is postoperative is verbalizing pain as a 2 on a 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?
1. "I think I should take my pain medication more often, since it is not controlling my pain."
2. "Breathing faster will help me keep my mind off of the pain."
3. "It might help me to listen to music while I'm lying in bed."
4. "I don't want to walk today because I have some pain." - ANS -3
Listening to music is an effective non pharmacological intervention for the management of mild pain.
\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 recently developed diarrhea. Which of the following findings should the
nurse identify as a possible cause of the diarrhea?
1. The client is receiving formula at room temperature.
2. The feedings infuse at a slow, continuous drip over 8 hr each night.
3. The client's caregiver washes out the feeding bag with warm water once every 24 hr.
4. The client's caregiver flushes the tubing with water before and after administering medications. - ANS -3
Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent
bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future
contamination.
\A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length
sequential compression sleeves. Which of the following actions should the nurse take?
1. Assist the client into a prone position.
2. Place a sleeve over the top of each leg with the opening at the knee.
3. Make sure two fingers can fit under the sleeves.
4. Set the ankle pressure at 65 mm Hg. - ANS -3
,The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space
between the sleeves and the legs can inhibit circulation when the sleeves inflate.
\A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which
the nurse should perform the following steps
1. Place a name tag on the body
2. Obtain the pronouncement of death from the provider
3. Remove the tubes and indwelling lines
4. Wash the clients body
5. Ask the clients family member if they would like to view the body - ANS -2,3,4,5,1
\A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative ans has fluid volume deficit. Which of
the following changes should the nurse identify as an indication that the treatment was successful?
1. Increase in hematocrit
2. Increase in respiratory rate
3. Decrease in heart rate
4. Decrease in capillary refill time - ANS -3
Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected
range.
\A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take
to ensure the medication reaches the inner ear?
1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min. - ANS -1
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
\A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the
following types of transmission precautions should the nurse initiate?
1. Protective environment
2. Airborne precautions
3. Droplet precautions
, 4. Contact precautions - ANS -4
Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All
caregivers should wear a gown and gloves during direct contact with this client.
\A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the
nurse initiate discharge planning?
1. During the admission process
2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family - ANS -1
Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to
assess the client's needs and plan for care both during and after the client's time in the facility.
\A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication
reconciliation?
1. Verify the client's name on their identification bracelet with the medication administration record.
2. Call the pharmacy to determine whether the client's medications are available.
3. Compare the client's home medications with the provider's prescriptions.
4. Place the client's home medication bottles in a secure location. - ANS -3
The nurse should compare the client's home medications with the provider's prescriptions when performing medication
reconciliation.
\A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the
nurse identify as an indication that the client has developed thrombophlebitis?
1. Bladder distention
2. Decreased blood pressure
3. Calf swelling
4. Diminished bowel sounds - ANS -3
Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of
immobility.
\A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions
should the nurse ask when assessing the quality of the clients pain?
A client who is postoperative is verbalizing pain as a 2 on a 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?
1. "I think I should take my pain medication more often, since it is not controlling my pain."
2. "Breathing faster will help me keep my mind off of the pain."
3. "It might help me to listen to music while I'm lying in bed."
4. "I don't want to walk today because I have some pain." - ANS -3
Listening to music is an effective non pharmacological intervention for the management of mild pain.
\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 recently developed diarrhea. Which of the following findings should the
nurse identify as a possible cause of the diarrhea?
1. The client is receiving formula at room temperature.
2. The feedings infuse at a slow, continuous drip over 8 hr each night.
3. The client's caregiver washes out the feeding bag with warm water once every 24 hr.
4. The client's caregiver flushes the tubing with water before and after administering medications. - ANS -3
Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent
bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future
contamination.
\A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length
sequential compression sleeves. Which of the following actions should the nurse take?
1. Assist the client into a prone position.
2. Place a sleeve over the top of each leg with the opening at the knee.
3. Make sure two fingers can fit under the sleeves.
4. Set the ankle pressure at 65 mm Hg. - ANS -3
,The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space
between the sleeves and the legs can inhibit circulation when the sleeves inflate.
\A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which
the nurse should perform the following steps
1. Place a name tag on the body
2. Obtain the pronouncement of death from the provider
3. Remove the tubes and indwelling lines
4. Wash the clients body
5. Ask the clients family member if they would like to view the body - ANS -2,3,4,5,1
\A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative ans has fluid volume deficit. Which of
the following changes should the nurse identify as an indication that the treatment was successful?
1. Increase in hematocrit
2. Increase in respiratory rate
3. Decrease in heart rate
4. Decrease in capillary refill time - ANS -3
Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected
range.
\A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take
to ensure the medication reaches the inner ear?
1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min. - ANS -1
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
\A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the
following types of transmission precautions should the nurse initiate?
1. Protective environment
2. Airborne precautions
3. Droplet precautions
, 4. Contact precautions - ANS -4
Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All
caregivers should wear a gown and gloves during direct contact with this client.
\A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the
nurse initiate discharge planning?
1. During the admission process
2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family - ANS -1
Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to
assess the client's needs and plan for care both during and after the client's time in the facility.
\A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication
reconciliation?
1. Verify the client's name on their identification bracelet with the medication administration record.
2. Call the pharmacy to determine whether the client's medications are available.
3. Compare the client's home medications with the provider's prescriptions.
4. Place the client's home medication bottles in a secure location. - ANS -3
The nurse should compare the client's home medications with the provider's prescriptions when performing medication
reconciliation.
\A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the
nurse identify as an indication that the client has developed thrombophlebitis?
1. Bladder distention
2. Decreased blood pressure
3. Calf swelling
4. Diminished bowel sounds - ANS -3
Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of
immobility.
\A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions
should the nurse ask when assessing the quality of the clients pain?
