Virtual ATI Fundamentals Pre-Assessment
Quiz
A charge nurse observes a nurse administer intermittent tube feeding via an NG tube to a client.
The charge nurse should take action for which of the following reasons? A. After aspirating 50
milliliters of gastric residual, the nurse begins the feeding. B. After feeding, the nurse uses tap
water to irrigate the NG tube. C. The nurse uses gravity to give the food through a syringe
barrel. D. The nurse allows the client to rest in a supine position during feeding. - ANS-The
nurse allows the client to rest in a supine position during feeding.
The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from
reflux during feedings.
A nurse in a long-term care facility enters the day room and finds the window curtains on fire.
Clients are panicking and the room is filling with smoke. Indicate the emergency actions the
nurse must take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.) - ANS-- Remove the clients from the room
- Activate the fire alarm
- Close the door
- Extinguish the fire
A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a
client who is worried about the outcome of a laboratory test. The nurse is demonstrating which
of the following ethical principles?
A. Autonomy
B. Justice
C. Fidelity
D. ANS-Fidelity - Nonmaleficence The nurse demonstrates the ethical principle of fidelity by
keeping a promise.
A nurse is assessing a client following the application of an aquathermia pad. Which of the
following is the first indication to the nurse that the client is experiencing a superficial burn injury
to the application site?
A. Blistering
B. Erythema
C. Eschar
D. ANS-B: absence of pain. Erythema
Erythema is an indication that the client has experienced a superficial burn with damage limited
to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following
findings associated with urinary retention should the nurse expect? (Select all that apply.) -
ANS-- Report of experiencing pressure - Tenderness over the symphysis pubis
- Distended bladder
, - Voiding 30 mL frequently
Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.
For an eight-hour shift, a nurse is calculating a client's intake and output. The client's intake
included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180 mL
bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse
document as the client's total intake for the shift? (Round the answer to the nearest whole
number) - ANS-1720 mL
A nurse is caring for a client who has returned to the unit following a surgical procedure. The
client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
A. Administer oxygen at 2 L/min.
B. Administer prescribed analgesic medication.
C. Encourage coughing and deep breathing.
D. Raise the head of the bed. - ANS-Raise the head of the bed.
Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the
abdominal organs and allows for increased expansion of the lungs. The head and neck can be
extended, which promotes a patent airway. This is the first action the nurse should take and is
the least invasive.
A patient with urinary incontinence is being cared for by a nurse. The nurse should take which
of the following steps to stop skin breakdown from happening? A. Apply a moisture barrier
ointment to the client's skin.
B. Clean the client's skin and perineum with hot water after each episode of incontinence.
C. Check the client's skin every 8 hr for signs of breakdown.
D. Request a prescription for the insertion of an indwelling urinary catheter. - ANS-Apply a
moisture barrier ointment to the client's skin.
Skin that remains in contact with urine for prolonged periods is at risk for maceration and
breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture
barrier ointment to prevent further contact of the skin with urine.
A nurse is caring for client who has a new diagnosis of type 1 diabetes mellitus. To focus on
effective learning with this client, which of the following interventions should the nurse use?
A. Ask the client to perform a return demonstration of insulin injection.
B. Review the action of insulin therapy.
C. Explore the client's feelings about dietary modifications.
D. Have the client practice blood-glucose monitoring using a glucometer. - ANS-Explore the
client's feelings about dietary modifications.
This teaching intervention allows the client to express his acceptance of this change and
focuses on affective learning.
A nurse is developing a plan of care for a client who is postoperative. Which of the following
interventions should the nurse include in the plan to prevent pulmonary complications?
A. Perform range-of-motion exercises
B. Set up suction equipment near the bed. C. Encourage the use of an incentive spirometer
D. Administer an expectorant - ANS-Encourage the use of an incentive spirometer
Incentive spirometry expands the lungs and promotes gas exchange after surgery which can
help prevent pulmonary complications.
Quiz
A charge nurse observes a nurse administer intermittent tube feeding via an NG tube to a client.
The charge nurse should take action for which of the following reasons? A. After aspirating 50
milliliters of gastric residual, the nurse begins the feeding. B. After feeding, the nurse uses tap
water to irrigate the NG tube. C. The nurse uses gravity to give the food through a syringe
barrel. D. The nurse allows the client to rest in a supine position during feeding. - ANS-The
nurse allows the client to rest in a supine position during feeding.
The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from
reflux during feedings.
A nurse in a long-term care facility enters the day room and finds the window curtains on fire.
Clients are panicking and the room is filling with smoke. Indicate the emergency actions the
nurse must take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.) - ANS-- Remove the clients from the room
- Activate the fire alarm
- Close the door
- Extinguish the fire
A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a
client who is worried about the outcome of a laboratory test. The nurse is demonstrating which
of the following ethical principles?
A. Autonomy
B. Justice
C. Fidelity
D. ANS-Fidelity - Nonmaleficence The nurse demonstrates the ethical principle of fidelity by
keeping a promise.
A nurse is assessing a client following the application of an aquathermia pad. Which of the
following is the first indication to the nurse that the client is experiencing a superficial burn injury
to the application site?
A. Blistering
B. Erythema
C. Eschar
D. ANS-B: absence of pain. Erythema
Erythema is an indication that the client has experienced a superficial burn with damage limited
to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following
findings associated with urinary retention should the nurse expect? (Select all that apply.) -
ANS-- Report of experiencing pressure - Tenderness over the symphysis pubis
- Distended bladder
, - Voiding 30 mL frequently
Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.
For an eight-hour shift, a nurse is calculating a client's intake and output. The client's intake
included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180 mL
bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse
document as the client's total intake for the shift? (Round the answer to the nearest whole
number) - ANS-1720 mL
A nurse is caring for a client who has returned to the unit following a surgical procedure. The
client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
A. Administer oxygen at 2 L/min.
B. Administer prescribed analgesic medication.
C. Encourage coughing and deep breathing.
D. Raise the head of the bed. - ANS-Raise the head of the bed.
Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the
abdominal organs and allows for increased expansion of the lungs. The head and neck can be
extended, which promotes a patent airway. This is the first action the nurse should take and is
the least invasive.
A patient with urinary incontinence is being cared for by a nurse. The nurse should take which
of the following steps to stop skin breakdown from happening? A. Apply a moisture barrier
ointment to the client's skin.
B. Clean the client's skin and perineum with hot water after each episode of incontinence.
C. Check the client's skin every 8 hr for signs of breakdown.
D. Request a prescription for the insertion of an indwelling urinary catheter. - ANS-Apply a
moisture barrier ointment to the client's skin.
Skin that remains in contact with urine for prolonged periods is at risk for maceration and
breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture
barrier ointment to prevent further contact of the skin with urine.
A nurse is caring for client who has a new diagnosis of type 1 diabetes mellitus. To focus on
effective learning with this client, which of the following interventions should the nurse use?
A. Ask the client to perform a return demonstration of insulin injection.
B. Review the action of insulin therapy.
C. Explore the client's feelings about dietary modifications.
D. Have the client practice blood-glucose monitoring using a glucometer. - ANS-Explore the
client's feelings about dietary modifications.
This teaching intervention allows the client to express his acceptance of this change and
focuses on affective learning.
A nurse is developing a plan of care for a client who is postoperative. Which of the following
interventions should the nurse include in the plan to prevent pulmonary complications?
A. Perform range-of-motion exercises
B. Set up suction equipment near the bed. C. Encourage the use of an incentive spirometer
D. Administer an expectorant - ANS-Encourage the use of an incentive spirometer
Incentive spirometry expands the lungs and promotes gas exchange after surgery which can
help prevent pulmonary complications.
