ATI Final Exam ~ Review
Questions and answers
2024\2025 A+ Grade
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of
the following instructions is appropriate for the client and family?
1. Remove the outer cannula cautiously for routine cleaning.
2. Use tracheostomy covers when outdoors.
3. Use sterile technique when performing tracheostomy care at home.
4. Cleanse irritated skin with full-strength hydrogen peroxide.
- correct answer 2. Use tracheostomy covers when outdoors.
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which
of the following pieces of information is most essential to provide?
1. Admitting diagnosis
2. Diagnostic test results
3. Body temperature
4. Breath sounds
- correct answer 4. Breath sounds
,**ABCs**
A nurse is checking blood pressures at a community health screening. Which of the following clients is at
high risk for primary hypertension?
1. A client who is pregnant
2. A client who has an elevated LDL
3. A client who takes oral contraceptives
4. A client who has kidney disease
- correct answer 2. A client who has an elevated LDL
A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of
the following tasks should the nurse assign to an AP? (Select all that apply.)
- Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Test the client's swallowing ability by providing thickened liquids.
- Use a communication board to ask what the client wants for lunch.
- Irrigate the client's indwelling urinary catheter.
- correct answer - Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Use a communication board to ask what the client wants for lunch.
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist
restraints after the client attempts to assault the admitting nurse. Which of the following actions is
appropriate for the nurse to take?
1. Tie restraints to the lower edge of the side rail.
2. Remove each restraint one at a time every 2 hr.
3. Ensure 3 finger-widths of space between the restraint and the client's wrist.
,4. Use a square knot to securely tie the restraints to the bed.
- correct answer 2. Remove each restraint one at a time every 2 hr.
**To perform ROM exercises and neurovascular checks**
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL.
Which of the following is an appropriate nursing intervention?
1. Return the unused medication to the automatic dispensing system.
2. Keep the remaining medication at the client's bedside for later use.
3. Have a second nurse witness the disposal of remaining medication.
4. Lock remaining medication in secure cabinet.
- correct answer 3. Have a second nurse witness the disposal of remaining medication.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is
an appropriate response by the nurse?
1. "It allows the court to overrule an adult client's refusal of medical treatment."
2. "It permits a client to withhold medical information from health care personnel."
3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness."
4. "It allows health care personnel in the emergency department to stabilize a client's condition."
- correct answer 3. "It indicates the form of treatment a client is willing to accept in the event of a
serious illness."
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client
was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct
documentation of this incident?
1. Incident report completed.
2. Client climbed over the bedrails.
3. Client found lying on floor.
, 4. Client was trying to get out of bed.
- correct answer 3. Client found lying on floor.
**remember, be Objective in documentation**
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands
that the preoperative teaching regarding pain control has been effective when the client states which of
the following?
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 may help me to listen to music while I'm lying in bed."
4. "I don't want to walk today, because I'm experiencing some pain."
- correct answer 3. "It may help me to listen to music while I'm lying in bed."
**nonpharmacological intervention to pain**
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse.
Which of the following is an appropriate response by the nurse?
1. "I'm sorry, but another client needed my attention."
2. "I arrived as soon as I could. What can I do for you?"
3. "It must be frustrating. I have a few minutes now."
4. "We had an emergency on the unit, but now I'm here."
- correct answer 3. "It must be frustrating. I have a few minutes now."
**therapeutic by acknowledging client's feelings**
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care,
when should the nurse initiate discharge planning?
Questions and answers
2024\2025 A+ Grade
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of
the following instructions is appropriate for the client and family?
1. Remove the outer cannula cautiously for routine cleaning.
2. Use tracheostomy covers when outdoors.
3. Use sterile technique when performing tracheostomy care at home.
4. Cleanse irritated skin with full-strength hydrogen peroxide.
- correct answer 2. Use tracheostomy covers when outdoors.
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which
of the following pieces of information is most essential to provide?
1. Admitting diagnosis
2. Diagnostic test results
3. Body temperature
4. Breath sounds
- correct answer 4. Breath sounds
,**ABCs**
A nurse is checking blood pressures at a community health screening. Which of the following clients is at
high risk for primary hypertension?
1. A client who is pregnant
2. A client who has an elevated LDL
3. A client who takes oral contraceptives
4. A client who has kidney disease
- correct answer 2. A client who has an elevated LDL
A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of
the following tasks should the nurse assign to an AP? (Select all that apply.)
- Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Test the client's swallowing ability by providing thickened liquids.
- Use a communication board to ask what the client wants for lunch.
- Irrigate the client's indwelling urinary catheter.
- correct answer - Assist the client with a partial bed bath.
- Measure the client's BP after the nurse administers an antihypertensive medication.
- Use a communication board to ask what the client wants for lunch.
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist
restraints after the client attempts to assault the admitting nurse. Which of the following actions is
appropriate for the nurse to take?
1. Tie restraints to the lower edge of the side rail.
2. Remove each restraint one at a time every 2 hr.
3. Ensure 3 finger-widths of space between the restraint and the client's wrist.
,4. Use a square knot to securely tie the restraints to the bed.
- correct answer 2. Remove each restraint one at a time every 2 hr.
**To perform ROM exercises and neurovascular checks**
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL.
Which of the following is an appropriate nursing intervention?
1. Return the unused medication to the automatic dispensing system.
2. Keep the remaining medication at the client's bedside for later use.
3. Have a second nurse witness the disposal of remaining medication.
4. Lock remaining medication in secure cabinet.
- correct answer 3. Have a second nurse witness the disposal of remaining medication.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is
an appropriate response by the nurse?
1. "It allows the court to overrule an adult client's refusal of medical treatment."
2. "It permits a client to withhold medical information from health care personnel."
3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness."
4. "It allows health care personnel in the emergency department to stabilize a client's condition."
- correct answer 3. "It indicates the form of treatment a client is willing to accept in the event of a
serious illness."
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client
was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct
documentation of this incident?
1. Incident report completed.
2. Client climbed over the bedrails.
3. Client found lying on floor.
, 4. Client was trying to get out of bed.
- correct answer 3. Client found lying on floor.
**remember, be Objective in documentation**
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands
that the preoperative teaching regarding pain control has been effective when the client states which of
the following?
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 may help me to listen to music while I'm lying in bed."
4. "I don't want to walk today, because I'm experiencing some pain."
- correct answer 3. "It may help me to listen to music while I'm lying in bed."
**nonpharmacological intervention to pain**
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse.
Which of the following is an appropriate response by the nurse?
1. "I'm sorry, but another client needed my attention."
2. "I arrived as soon as I could. What can I do for you?"
3. "It must be frustrating. I have a few minutes now."
4. "We had an emergency on the unit, but now I'm here."
- correct answer 3. "It must be frustrating. I have a few minutes now."
**therapeutic by acknowledging client's feelings**
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care,
when should the nurse initiate discharge planning?
