ATI Fundamentals Practice Quiz
Mastering Medical-Surgical Nursing:
Clinical Decision-Making Scenarios
1. Aging Changes: Client Education Effectiveness
Scenario: A nurse teaches older adults about expected aging changes.
Client Statement Indicating Understanding: "I should expect my heart
rate to take longer to return to normal after exercise as I get older."
Rationale: As individuals age, decreased cardiac output leads to an
increased heart rate during exercise, and the heart rate takes longer to return
to baseline due to physiological changes in the cardiovascular system.
2. Postoperative Paralytic Ileus: Expected Abdominal Assessment
Scenario: A postoperative patient has paralytic ileus.
Expected Assessment Finding: Absent bowel sounds with distention.
Rationale: Paralytic ileus involves a decrease or absence of bowel motility.
This results in a lack of peristalsis and the accumulation of gas and fluid,
leading to abdominal distention and absent bowel sounds.
3. Abdominal Pain Assessment: Identifying the Priority Finding
Scenario: A client with abdominal pain has a temperature of 102.6°F, heart
rate of 105 bpm, soft non-tender abdomen, and is 2 days overdue for
menses.
Priority Finding: Temperature of 102.6°F.
Rationale: An elevated temperature indicates a potential acute infection or
inflammatory process, representing an immediate physiological need
according to Maslow's Hierarchy of Needs. This requires prompt nursing
intervention.
,4. Post-Tonsillectomy Care (Child): Key Instruction
Scenario: Providing instructions for a child postoperative following a
tonsillectomy.
Instruction to Follow: Administer analgesics to the child on a routine
schedule throughout the day.
Rationale: Consistent pain management is crucial after a tonsillectomy to
soothe the throat, encourage swallowing, and promote comfort, facilitating
recovery.
5. Cardiac Auscultation: Documenting Pericardial Friction Rub
Scenario: A nurse auscultates a high-pitched scratching sound during
diastole at the left sternal border.
Heart Sound to Document: Pericardial friction rub.
Rationale: A pericardial friction rub is characterized by a scratching,
grating, or squeaking sound, often high-pitched and best heard with the
diaphragm at the left sternal border. It is associated with inflammation of the
pericardial layers.
6. Hand Hygiene Education: Assistive Personnel Understanding
Scenario: A nurse teaches an assistive personnel (AP) about proper hand
hygiene.
AP Statement Indicating Understanding: "There are times I should use
soap and water instead of alcohol-based sanitizer."
Rationale: While alcohol-based hand rubs are effective, the CDC
recommends soap and water for visibly soiled hands or after contact with
bodily fluids.
7. Unstable Client Monitoring: Addressing Inconsistent Electronic BP
Readings
Scenario: An unstable client's electronic BP machine provides inconsistent
readings.
Appropriate Action: Disconnect the machine and measure the BP
manually every 15 minutes.
Rationale: If the reliability of electronic monitoring is questionable, manual
measurement is necessary to ensure accurate and timely assessment of the
unstable client's blood pressure. Malfunctioning equipment should be
removed to prevent safety risks.
, 8. Heart Failure Education: Enhancing Dietary Learning
Scenario: Teaching a client with heart failure about reducing sodium intake.
Most Important Factor for Learning: The involvement of the client in
planning the change.
Rationale: Evidence-based practice indicates that client participation in
planning dietary modifications significantly improves their understanding,
motivation, and adherence to new habits.
9. Pediatric Vital Signs: Appropriate Temperature Route (2-Year-Old)
Scenario: Obtaining vital signs for a 2-year-old with diarrhea and suspected
ear infection.
Recommended Temperature Route: Temporal.
Rationale: The temporal artery thermometer is non-invasive, quick, and
well-tolerated by toddlers, especially one who may be uncomfortable due to
an ear infection and experiencing diarrhea.
10. Informed Consent: Nurse's Role as Witness
Scenario: A nurse witnesses a client signing an informed consent form for
surgery.
Nurse's Affirmation: The signature on the pre-op consent form is the
client's.
Rationale: The nurse's role as a witness is to verify that the client signing
the form is indeed the person identified and that the signature is theirs. The
provider is responsible for explaining the procedure, risks, and benefits.
11. Surgical Handwashing: Proper Technique
Scenario: A nurse performs surgical handwashing before assisting in a
surgical procedure.
Action Indicating Proper Technique: Nurse washes with hands held
higher than elbows.
Rationale: Holding the hands higher than the elbows during surgical
handwashing ensures that water and soap flow from the clean area (hands)
towards the less clean area (elbows), preventing recontamination.
12. Cardiac Auscultation: Aortic Valve Location
Scenario: Assessing a client with a history of aortic valve stenosis.
Mastering Medical-Surgical Nursing:
Clinical Decision-Making Scenarios
1. Aging Changes: Client Education Effectiveness
Scenario: A nurse teaches older adults about expected aging changes.
Client Statement Indicating Understanding: "I should expect my heart
rate to take longer to return to normal after exercise as I get older."
Rationale: As individuals age, decreased cardiac output leads to an
increased heart rate during exercise, and the heart rate takes longer to return
to baseline due to physiological changes in the cardiovascular system.
2. Postoperative Paralytic Ileus: Expected Abdominal Assessment
Scenario: A postoperative patient has paralytic ileus.
Expected Assessment Finding: Absent bowel sounds with distention.
Rationale: Paralytic ileus involves a decrease or absence of bowel motility.
This results in a lack of peristalsis and the accumulation of gas and fluid,
leading to abdominal distention and absent bowel sounds.
3. Abdominal Pain Assessment: Identifying the Priority Finding
Scenario: A client with abdominal pain has a temperature of 102.6°F, heart
rate of 105 bpm, soft non-tender abdomen, and is 2 days overdue for
menses.
Priority Finding: Temperature of 102.6°F.
Rationale: An elevated temperature indicates a potential acute infection or
inflammatory process, representing an immediate physiological need
according to Maslow's Hierarchy of Needs. This requires prompt nursing
intervention.
,4. Post-Tonsillectomy Care (Child): Key Instruction
Scenario: Providing instructions for a child postoperative following a
tonsillectomy.
Instruction to Follow: Administer analgesics to the child on a routine
schedule throughout the day.
Rationale: Consistent pain management is crucial after a tonsillectomy to
soothe the throat, encourage swallowing, and promote comfort, facilitating
recovery.
5. Cardiac Auscultation: Documenting Pericardial Friction Rub
Scenario: A nurse auscultates a high-pitched scratching sound during
diastole at the left sternal border.
Heart Sound to Document: Pericardial friction rub.
Rationale: A pericardial friction rub is characterized by a scratching,
grating, or squeaking sound, often high-pitched and best heard with the
diaphragm at the left sternal border. It is associated with inflammation of the
pericardial layers.
6. Hand Hygiene Education: Assistive Personnel Understanding
Scenario: A nurse teaches an assistive personnel (AP) about proper hand
hygiene.
AP Statement Indicating Understanding: "There are times I should use
soap and water instead of alcohol-based sanitizer."
Rationale: While alcohol-based hand rubs are effective, the CDC
recommends soap and water for visibly soiled hands or after contact with
bodily fluids.
7. Unstable Client Monitoring: Addressing Inconsistent Electronic BP
Readings
Scenario: An unstable client's electronic BP machine provides inconsistent
readings.
Appropriate Action: Disconnect the machine and measure the BP
manually every 15 minutes.
Rationale: If the reliability of electronic monitoring is questionable, manual
measurement is necessary to ensure accurate and timely assessment of the
unstable client's blood pressure. Malfunctioning equipment should be
removed to prevent safety risks.
, 8. Heart Failure Education: Enhancing Dietary Learning
Scenario: Teaching a client with heart failure about reducing sodium intake.
Most Important Factor for Learning: The involvement of the client in
planning the change.
Rationale: Evidence-based practice indicates that client participation in
planning dietary modifications significantly improves their understanding,
motivation, and adherence to new habits.
9. Pediatric Vital Signs: Appropriate Temperature Route (2-Year-Old)
Scenario: Obtaining vital signs for a 2-year-old with diarrhea and suspected
ear infection.
Recommended Temperature Route: Temporal.
Rationale: The temporal artery thermometer is non-invasive, quick, and
well-tolerated by toddlers, especially one who may be uncomfortable due to
an ear infection and experiencing diarrhea.
10. Informed Consent: Nurse's Role as Witness
Scenario: A nurse witnesses a client signing an informed consent form for
surgery.
Nurse's Affirmation: The signature on the pre-op consent form is the
client's.
Rationale: The nurse's role as a witness is to verify that the client signing
the form is indeed the person identified and that the signature is theirs. The
provider is responsible for explaining the procedure, risks, and benefits.
11. Surgical Handwashing: Proper Technique
Scenario: A nurse performs surgical handwashing before assisting in a
surgical procedure.
Action Indicating Proper Technique: Nurse washes with hands held
higher than elbows.
Rationale: Holding the hands higher than the elbows during surgical
handwashing ensures that water and soap flow from the clean area (hands)
towards the less clean area (elbows), preventing recontamination.
12. Cardiac Auscultation: Aortic Valve Location
Scenario: Assessing a client with a history of aortic valve stenosis.
