ATI RN CONCEPT-BASED ASSESSMENT LEVEL 1 2025 |
COMPREHENSIVE 100% CORRECT QUESTION &
ANSWERS EXAM WITH DETAILED RATIONALES
1. A nurse is caring for a client 2 days postoperative following an above-the-knee amputation.
The client reports a dull, burning sensation in the amputated limb. What is the best nursing
action?
a) Administer prescribed opioid analgesics and provide comfort measures
b) Notify the healthcare provider immediately for possible infection
c) Reassure the client that this is phantom limb pain and provide pain management
d) Apply cold compresses to the residual limb
Correct: c
Explanation: Phantom limb pain is common after amputation and manifests as burning or dull
sensations in the missing limb. The nurse should reassure the client and provide appropriate
pain management, including medications and non-pharmacological interventions.
2. A client with chronic obstructive pulmonary disease (COPD) is prescribed a beta-2 agonist
inhaler. Which instruction should the nurse include?
a) Use the inhaler only when experiencing shortness of breath
b) Rinse your mouth after each use to prevent fungal infections
c) Limit fluid intake to reduce mucus production
d) Avoid using the inhaler before exercise
Correct: b
Explanation: Beta-2 agonists can increase the risk of oral candidiasis; rinsing the mouth after
use reduces this risk. These inhalers are often used for maintenance and prevention, not just
during acute symptoms.
3. A nurse is teaching a client about warfarin therapy. Which statement indicates the client
understands the teaching?
a) "I will avoid eating foods high in vitamin K like spinach and kale."
b) "I should stop taking warfarin if I notice any bruising."
c) "I need to have my blood tested regularly to check my INR levels."
d) "I can take aspirin for headaches while on warfarin."
Correct: c
Explanation: Regular INR monitoring is essential to ensure therapeutic anticoagulation and
,prevent bleeding or clotting complications. Clients should not abruptly stop warfarin without
consulting their provider.
4. A client with type 2 diabetes is prescribed metformin. Which finding indicates a possible
adverse effect?
a) Dry mouth
b) Persistent cough
c) Muscle weakness and fatigue
d) Abdominal bloating and diarrhea
Correct: d
Explanation: Gastrointestinal side effects such as diarrhea and bloating are common with
metformin. Muscle weakness and fatigue could indicate lactic acidosis, a rare but serious
adverse effect requiring immediate attention.
5. A nurse is caring for a client receiving intravenous potassium chloride. Which assessment
finding requires immediate intervention?
a) Serum potassium level of 4.5 mEq/L
b) Reports of palpitations and muscle weakness
c) Mild nausea after infusion
d) Slight redness at the IV site
Correct: b
Explanation: Palpitations and muscle weakness may indicate hyperkalemia, which can cause
life-threatening cardiac arrhythmias. Immediate assessment and intervention are required.
6. A client is prescribed lisinopril for hypertension. Which adverse effect should the nurse
monitor for?
a) Persistent dry cough
b) Tachycardia
c) Hyperglycemia
d) Constipation
Correct: a
Explanation: ACE inhibitors like lisinopril commonly cause a persistent dry cough due to
increased bradykinin.
7. A nurse is teaching a client about the use of albuterol inhaler. Which statement by the client
indicates understanding?
, a) "I will use this inhaler before exercise to prevent wheezing."
b) "I should use this inhaler only when I feel short of breath."
c) "I will rinse my mouth after using this inhaler."
d) "This inhaler is a steroid and may take weeks to work."
Correct: a
Explanation: Albuterol is a short-acting beta-2 agonist used as a rescue inhaler and can be used
prophylactically before exercise to prevent bronchospasm.
8. Which laboratory value should the nurse monitor closely in a client receiving heparin
therapy?
a) Prothrombin time (PT)
b) Activated partial thromboplastin time (aPTT)
c) International normalized ratio (INR)
d) Platelet count
Correct: b
Explanation: aPTT is used to monitor heparin therapy to ensure therapeutic anticoagulation.
9. A client is prescribed digoxin for heart failure. Which finding indicates digoxin toxicity?
a) Bradycardia and visual disturbances
b) Hypertension and dry mouth
c) Tachycardia and sweating
d) Constipation and headache
Correct: a
Explanation: Bradycardia and visual disturbances such as yellow-green halos are classic signs of
digoxin toxicity.
10. A nurse is caring for a client with a new colostomy. Which statement by the client indicates
the need for further teaching?
a) "I should expect some gas and odor from the stoma."
b) "I can eat whatever I want without any problems."
c) "I will clean the skin around the stoma gently with warm water."
d) "I need to empty the pouch when it is one-third full."
Correct: b
Explanation: Clients should be taught about dietary modifications to prevent gas, odor, and
blockage. Saying they can eat anything indicates a need for further education.
COMPREHENSIVE 100% CORRECT QUESTION &
ANSWERS EXAM WITH DETAILED RATIONALES
1. A nurse is caring for a client 2 days postoperative following an above-the-knee amputation.
The client reports a dull, burning sensation in the amputated limb. What is the best nursing
action?
a) Administer prescribed opioid analgesics and provide comfort measures
b) Notify the healthcare provider immediately for possible infection
c) Reassure the client that this is phantom limb pain and provide pain management
d) Apply cold compresses to the residual limb
Correct: c
Explanation: Phantom limb pain is common after amputation and manifests as burning or dull
sensations in the missing limb. The nurse should reassure the client and provide appropriate
pain management, including medications and non-pharmacological interventions.
2. A client with chronic obstructive pulmonary disease (COPD) is prescribed a beta-2 agonist
inhaler. Which instruction should the nurse include?
a) Use the inhaler only when experiencing shortness of breath
b) Rinse your mouth after each use to prevent fungal infections
c) Limit fluid intake to reduce mucus production
d) Avoid using the inhaler before exercise
Correct: b
Explanation: Beta-2 agonists can increase the risk of oral candidiasis; rinsing the mouth after
use reduces this risk. These inhalers are often used for maintenance and prevention, not just
during acute symptoms.
3. A nurse is teaching a client about warfarin therapy. Which statement indicates the client
understands the teaching?
a) "I will avoid eating foods high in vitamin K like spinach and kale."
b) "I should stop taking warfarin if I notice any bruising."
c) "I need to have my blood tested regularly to check my INR levels."
d) "I can take aspirin for headaches while on warfarin."
Correct: c
Explanation: Regular INR monitoring is essential to ensure therapeutic anticoagulation and
,prevent bleeding or clotting complications. Clients should not abruptly stop warfarin without
consulting their provider.
4. A client with type 2 diabetes is prescribed metformin. Which finding indicates a possible
adverse effect?
a) Dry mouth
b) Persistent cough
c) Muscle weakness and fatigue
d) Abdominal bloating and diarrhea
Correct: d
Explanation: Gastrointestinal side effects such as diarrhea and bloating are common with
metformin. Muscle weakness and fatigue could indicate lactic acidosis, a rare but serious
adverse effect requiring immediate attention.
5. A nurse is caring for a client receiving intravenous potassium chloride. Which assessment
finding requires immediate intervention?
a) Serum potassium level of 4.5 mEq/L
b) Reports of palpitations and muscle weakness
c) Mild nausea after infusion
d) Slight redness at the IV site
Correct: b
Explanation: Palpitations and muscle weakness may indicate hyperkalemia, which can cause
life-threatening cardiac arrhythmias. Immediate assessment and intervention are required.
6. A client is prescribed lisinopril for hypertension. Which adverse effect should the nurse
monitor for?
a) Persistent dry cough
b) Tachycardia
c) Hyperglycemia
d) Constipation
Correct: a
Explanation: ACE inhibitors like lisinopril commonly cause a persistent dry cough due to
increased bradykinin.
7. A nurse is teaching a client about the use of albuterol inhaler. Which statement by the client
indicates understanding?
, a) "I will use this inhaler before exercise to prevent wheezing."
b) "I should use this inhaler only when I feel short of breath."
c) "I will rinse my mouth after using this inhaler."
d) "This inhaler is a steroid and may take weeks to work."
Correct: a
Explanation: Albuterol is a short-acting beta-2 agonist used as a rescue inhaler and can be used
prophylactically before exercise to prevent bronchospasm.
8. Which laboratory value should the nurse monitor closely in a client receiving heparin
therapy?
a) Prothrombin time (PT)
b) Activated partial thromboplastin time (aPTT)
c) International normalized ratio (INR)
d) Platelet count
Correct: b
Explanation: aPTT is used to monitor heparin therapy to ensure therapeutic anticoagulation.
9. A client is prescribed digoxin for heart failure. Which finding indicates digoxin toxicity?
a) Bradycardia and visual disturbances
b) Hypertension and dry mouth
c) Tachycardia and sweating
d) Constipation and headache
Correct: a
Explanation: Bradycardia and visual disturbances such as yellow-green halos are classic signs of
digoxin toxicity.
10. A nurse is caring for a client with a new colostomy. Which statement by the client indicates
the need for further teaching?
a) "I should expect some gas and odor from the stoma."
b) "I can eat whatever I want without any problems."
c) "I will clean the skin around the stoma gently with warm water."
d) "I need to empty the pouch when it is one-third full."
Correct: b
Explanation: Clients should be taught about dietary modifications to prevent gas, odor, and
blockage. Saying they can eat anything indicates a need for further education.
