ATI RN Concept Based Assessment Level 3
Practice A UPDATED ACTUAL Exam
Questions and CORRECT Answers
A nurse is caring for an older adult client who has kidney failure. The client tells the nurse that
she has decided to stop hemodialysis treatment. Which of the following actions by the nurse is
appropriate in regard to serving as the client's advocate? - CORRECT ANSWER -
Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue treatment.
A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L over 4
hr instead of over 8 hr as prescribed. Which of the following entries is the appropriate
documentation of this occurrence in the client's medical record? - CORRECT ANSWER -
0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse should document
the amount of fluid, how long it took to infuse, and the client's physical status.
When planning care for a child who has increased intracranial pressure (ICP), which of the
following should the nurse include in the child's plan of care? - CORRECT ANSWER -
Maintain head in midline. -The child's head should be maintained in a midline position to
promote venous return and prevent an increase in ICP.
- CORRECT ANSWER - Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased
ICP.
A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that she is
mourning the loss of her hair. Which of the following actions should the nurse take first? -
CORRECT ANSWER - Discuss the importance of hair with the client.--The first action
the nurse should take using the nursing process is to assess the client. By identifying the
,importance of hair to the client, the nurse can acknowledge the importance of the expected loss
to the client and assist the client with anticipatory grieving.
- CORRECT ANSWER - an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math skills, such
as managing finances.
- CORRECT ANSWER - Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
- CORRECT ANSWER - Discontinue the infusion.--A report of pain and a red line
extending outward from the insertion site are manifestations of phlebitis and indicates that the
client is at the greatest risk from injury to the vein; therefore, the first action the nurse should
take is to discontinue the infusion.
A client who is being discharged today asks the nurse for supplies for her wound dressing.
Which of the following actions should the nurse take to ensure quality, cost-effective care? -
CORRECT ANSWER - Provide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the facility, it may be
necessary to provide adequate supplies for the immediate discharge period.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the
following should the nurse document as a therapeutic outcome? - CORRECT ANSWER -
Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for improved muscle
function.
A nurse is providing postoperative instructions about complete proteins to a client following a
below-the-knee amputation. Which of the following food choices indicates a need for additional
instruction? - CORRECT ANSWER - Pinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
, A community health nurse is asked to give a health education program to a group of African-
American men age 40 to 75. Considering the health concerns of this group, which of the
following topics is most important to include in the program? - CORRECT ANSWER -
Prostate cancer screening-
The greatest risk for African-American males is death from prostate cancer. Therefore, prostate
cancer screening is the priority topic to include.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The
provider has explained the procedure to the client. Which of the following statements made by
the client indicates a need for further teaching? - CORRECT ANSWER - "This procedure
can increase my risk for developing Parkinson's disease."-
Developing Parkinson's disease is not an adverse effect of ECT; therefore, this statement
indicates a need for further teaching.
A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The client
reports leakage and irritation around the stoma. Which of the following is an appropriate
intervention? - CORRECT ANSWER - Instruct the client to use a skin barrier when
refitting the pouch system.-
The client should use a skin barrier to protect the skin from enzymes and bile salts from
gastrointestinal drainage at the stoma site.
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose
tolerance test. Which of the following should the nurse include in her teaching? - CORRECT
ANSWER - Consume 150 g of carbohydrates daily for 3 days prior to the test.-
A carbohydrate load prior to the glucose tolerance test is necessary for an accurate assessment.
A client with a diagnosis of depression is attending group therapy. During the group meeting, the
nurse asks each member to identify one goal for the day. When it is the client's turn, she does not
respond. Which of the following should the nurse do before repeating the request to the client? -
CORRECT ANSWER - Allow the client time to collect her thoughts. -
Clients who have depression often experience delayed thinking and require extra time to respond
to questions. The nurse should allow the client time to formulate a response.
Practice A UPDATED ACTUAL Exam
Questions and CORRECT Answers
A nurse is caring for an older adult client who has kidney failure. The client tells the nurse that
she has decided to stop hemodialysis treatment. Which of the following actions by the nurse is
appropriate in regard to serving as the client's advocate? - CORRECT ANSWER -
Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue treatment.
A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L over 4
hr instead of over 8 hr as prescribed. Which of the following entries is the appropriate
documentation of this occurrence in the client's medical record? - CORRECT ANSWER -
0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse should document
the amount of fluid, how long it took to infuse, and the client's physical status.
When planning care for a child who has increased intracranial pressure (ICP), which of the
following should the nurse include in the child's plan of care? - CORRECT ANSWER -
Maintain head in midline. -The child's head should be maintained in a midline position to
promote venous return and prevent an increase in ICP.
- CORRECT ANSWER - Sleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from
sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased
ICP.
A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that she is
mourning the loss of her hair. Which of the following actions should the nurse take first? -
CORRECT ANSWER - Discuss the importance of hair with the client.--The first action
the nurse should take using the nursing process is to assess the client. By identifying the
,importance of hair to the client, the nurse can acknowledge the importance of the expected loss
to the client and assist the client with anticipatory grieving.
- CORRECT ANSWER - an inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math skills, such
as managing finances.
- CORRECT ANSWER - Fine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
- CORRECT ANSWER - Discontinue the infusion.--A report of pain and a red line
extending outward from the insertion site are manifestations of phlebitis and indicates that the
client is at the greatest risk from injury to the vein; therefore, the first action the nurse should
take is to discontinue the infusion.
A client who is being discharged today asks the nurse for supplies for her wound dressing.
Which of the following actions should the nurse take to ensure quality, cost-effective care? -
CORRECT ANSWER - Provide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the facility, it may be
necessary to provide adequate supplies for the immediate discharge period.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the
following should the nurse document as a therapeutic outcome? - CORRECT ANSWER -
Decrease in flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for improved muscle
function.
A nurse is providing postoperative instructions about complete proteins to a client following a
below-the-knee amputation. Which of the following food choices indicates a need for additional
instruction? - CORRECT ANSWER - Pinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
, A community health nurse is asked to give a health education program to a group of African-
American men age 40 to 75. Considering the health concerns of this group, which of the
following topics is most important to include in the program? - CORRECT ANSWER -
Prostate cancer screening-
The greatest risk for African-American males is death from prostate cancer. Therefore, prostate
cancer screening is the priority topic to include.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The
provider has explained the procedure to the client. Which of the following statements made by
the client indicates a need for further teaching? - CORRECT ANSWER - "This procedure
can increase my risk for developing Parkinson's disease."-
Developing Parkinson's disease is not an adverse effect of ECT; therefore, this statement
indicates a need for further teaching.
A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The client
reports leakage and irritation around the stoma. Which of the following is an appropriate
intervention? - CORRECT ANSWER - Instruct the client to use a skin barrier when
refitting the pouch system.-
The client should use a skin barrier to protect the skin from enzymes and bile salts from
gastrointestinal drainage at the stoma site.
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose
tolerance test. Which of the following should the nurse include in her teaching? - CORRECT
ANSWER - Consume 150 g of carbohydrates daily for 3 days prior to the test.-
A carbohydrate load prior to the glucose tolerance test is necessary for an accurate assessment.
A client with a diagnosis of depression is attending group therapy. During the group meeting, the
nurse asks each member to identify one goal for the day. When it is the client's turn, she does not
respond. Which of the following should the nurse do before repeating the request to the client? -
CORRECT ANSWER - Allow the client time to collect her thoughts. -
Clients who have depression often experience delayed thinking and require extra time to respond
to questions. The nurse should allow the client time to formulate a response.
