ATI RN CONCEPT BASED
ASSESSMENT LEVEL 1
A01nurse01is01caring01for01a01client01who01is01201days01postoperative01following01an01abo
ve-the-
knee01amputation.01The01client01states01he01is01experiencing01a01dull,01burning01pain01in
01the01leg01that01was01amputated.01Which01of01the01following01actions01should01the01nur
se01take01to01treat01the01client's01neuropathic01pain?01-01answer--Administer01a01beta-
blocking01medication01to01the01client.
(The01nurse01should01administer01a01beta-
blocking01medication01to01the01client.01This01classification01of01medication01has01been01
shown01to01relieve01the01phantom01limb01pain01manifestations01of01constant01dull01and01
burning01type01pain.)
A01newly01licensed01nurse01asks01a01charge01nurse01where01to01find01information01abou
t01scope01of01practice01for01registered01nurses.01Which01of01the01following01responses01
should01the01charge01nurse01make?01-
01answer--"The01state01board01of01nursing01can01provide01this01information"
(each01state01develops01a01nurse01practice01act,01which01defines01scope01of01practice01f
or01nurses01in01that01state.01This01practice01act01is01available01on01the01board01of01nursi
ng01website01for01each01state.)
A01nurse01is01planning01care01to01prevent01a01catheter-
related01bloodstream01infection01for01a01client01who01is01receiving01IV01fluid01therapy.01
Which01of01the01following01interventions01should01the01nurse01include01in01the01plan?01-
01answer--Perform01hand01hygiene01before01touching01the01IV01tubing.
(The01nurse01should01perform01thorough01hand01hygiene01before01touching01any01part01
of01the01infusion01system01or01the01client01to01reduce01the01risk01of01catheter-
related01blood01stream01infections.)
A01nurse01is01creating01a01plan01of01care01for01a01client01who01is01non-
ambulatory01and01has01bladder01and01bowel01incontinence.01Which01of01the01following01
interventions01should01the01nurse01include01to01prevent01skin01breakdown?01-01answer--
Offer01the01client01a01glass01of01water01every01two01hour01when01repositioning.
(The01nurse01should01offer01the01client01a01glass01of01water01every01two01hours01on01the
01clients01repositioning01schedule.01This01helps01prevent01dehydration,01which01increase
s01the01risk01of01skin01breakdown.)
,A01nurse01is01teaching01a01young01adult01female01client01about01health01screening01for01
breast01cancer.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01breast01self-examination01(BSE)?01-
01answer--"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01ea
ch01breast."
(The01nurse01should01instruct01the01client01at01a01firm01ridge01is01expected01along01the01
bottom01curve01of01each01breast.01The01client01should01be01able01to01feel01this01area01d
uring01the01BSE.01Performing01a01BSE01promotes01breast01self01awareness01so01that01t
he01client01knows01how01her01breast01normally01feel.01The01awareness01increases01the0
1clients01ability01to01identify01changes01that01require01further01evaluation.)
A01nurse01is01caring01for01an01adolescent01who01is01in01critical01condition01following01a01
motor01vehicle01crash01which01he01was01the01passenger.01The01clients01parent01shout01
at01the01nurse,01asking01why01her01son01is01dying01instead01of01the01driver.01Which01of01
the01following01actions01should01the01nurse01take01to01provide01emotional01support01to01t
he01parent?01-01answer--
Inform01the01parent01that01anger01is01a01natural01response01when01dealing01with01loss.
(The01nurse01should01identify01that01the01parent01is01in01the01anger01stage01of01grief.01T
he01nurse01should01assist01the01parent01to01understand01that01anger01is01a01natural01res
ponse01to01loss01and01encourage01her01to01talk01about01her01feelings.)
A01nurse01is01teaching01an01older01adult01client01about01accessing01electronic01resource
s01for01healthcare01information01on01the01internet.01Which01of01the01following01statement
s01should01the01nurse01include01in01the01teaching?01-
01answer--"Websites01ending01in01'.gov'01are01reliable01sites01for01obtaining01health01info
rmation01from01government01agencies."
(The01nurse01should01teach01the01client01how01to01select01reliable01internet01websites01
when01researching01health01care01information.01The01nurse01should01identify01that01web
sites01ending01in01'.gov'01and01'.edu'01are01considered01reliable01and01credible01sources0
1for01health01information.01Websites01ending01in01'.com'01should01not01be01used01for01re
searching01credible01healthcare01information.)
A01nurse01enters01a01clients01room01and01finds01the01client01lying01on01the01floor.01The01
client01states01that01on01the01way01to01the01bathroom01her01"knee01locked,"01causing01h
er01to01fall.01Which01of01the01following01actions01should01the01nurse01take01first?01-
01answer--Check01the01client01for01injuries.
(The01first01action01the01nurse01should01take01when01using01the01nursing01process01is01t
o01assess01the01client.01The01nurse01should01first01check01the01client01for01injuries01and0
1measure01vital01signs01to01help01determine01physiologic01stability.01The01nurse01should
01also01inform01the01provider01of01the01clients01fall01and01of01the01assessment01findings.)
A01nurse01is01teaching01a01client01who01has01rheumatoid01arthritis01about01chronic01pain
01management.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01the01teaching?01-
01answer--"I01should01use01a01warm01paraffin01dip01for01my01hands01and01feet."
, (The01nurse01should01instruct01the01client01to01dip01her01hands01and01feet01in01warm01pa
raffin01to01alleviate01pain01and01stiffness.01The01client01can01more01easily01perform01han
d01and01finger01exercises01following01the01treatment.)
A01community01health01nurse01is01planning01prevention01strategies01for01hypertension01
among01members01of01her01community.01The01nurse01should01identify01that01which01of01
the01following01ethnic01groups01in01the01community01is01at01greatest01risk01of01developin
g01hypertension?01-01answer--African01American
(Evidence-
based01practice01indicates01that01individuals01of01AA01ethnicity01have01the01highest01pre
valence01of01hypertension.01Therefore,01the01nurse01should01identify01community01mem
bers01of01this01ethnicity01are01at01greatest01risk01of01developing01hypertension.)
A01nurse01is01preparing01to01extinguish01a01small01fire01in01a01clients01room.01Which01of0
1the01following01actions01should01the01nurse01take01when01using01the01fire01extinguisher
?01-01answer--Slide01the01pin01on01top01of01the01fire01extinguisher01straight01out.
(The01nurse01should01pull01the01pin01on01top01of01the01fire01extinguisher01to01allow01for01
use01to01extinguish01the01fire.)
A01nurse01is01preparing01to01administer01intermittent01external01nutrition01via01a01clients0
1NG01tube.01In01which01order01should01the01nurse01take01the01following01actions?01-
01answer--1.01Assist01the01client01to01an01upright01position.
2.01Aspirate01501mL01of01gastric01contents.
3.01Test01the01pH01of01gastric01aspirate.
4.01Measure01gastric01residual01volume.
5.01Flush01the01NG01tube01with013001mL01of01water.
(First,01the01nurse01should01assist01the01client01into01high01Fowler's01position01or01raise0
1the01HOB01at01least013001degrees01to01help01prevent01aspiration.01Then,01the01nurse01s
hould01verify01the01tubes01placement01by01aspirating01501mL01of01gastric01contents01and
01then01testing01the01pH.01Then,01the01nurse01should01check01for01gastric01residual01volu
me.01Excessive01GRV01is01an01indication01of01delayed01gastric01emptying,01which01plac
es01the01client01at01risk01of01aspiration01if01additional01formula01is01given.01Finally,01the01
nurse01should01flush01the01tubing01with013001mL01of01water01to01ensure01the01tube01is01c
lear01and01patent.)
A01nurse01is01caring01for01a0147-year-
old01female01client01who01had01urinary01incontinence.01Which01of01the01following01action
s01should01the01nurse01take01first?01-01answer--
Obtain01a01specimen01from01the01client01for01culture.
(The01first01action01the01nurse01should01take01when01using01the01nursing01process01is01a
ssessment.01The01nurse01should01obtain01a01urine01specimen01from01the01client01to01rul
e01out01a01UTI.01If01it01is01a01determined01the01client01has01RBC's01and01WBC's01in01the0
1urine,01the01specimen01will01require01a01culture.01If01it01is01determined01that01the01client
01has01a01UTI,01this01will01require01treatment01before01any01further01assessment01of01inc
ontinence01would01be01indicated.)
ASSESSMENT LEVEL 1
A01nurse01is01caring01for01a01client01who01is01201days01postoperative01following01an01abo
ve-the-
knee01amputation.01The01client01states01he01is01experiencing01a01dull,01burning01pain01in
01the01leg01that01was01amputated.01Which01of01the01following01actions01should01the01nur
se01take01to01treat01the01client's01neuropathic01pain?01-01answer--Administer01a01beta-
blocking01medication01to01the01client.
(The01nurse01should01administer01a01beta-
blocking01medication01to01the01client.01This01classification01of01medication01has01been01
shown01to01relieve01the01phantom01limb01pain01manifestations01of01constant01dull01and01
burning01type01pain.)
A01newly01licensed01nurse01asks01a01charge01nurse01where01to01find01information01abou
t01scope01of01practice01for01registered01nurses.01Which01of01the01following01responses01
should01the01charge01nurse01make?01-
01answer--"The01state01board01of01nursing01can01provide01this01information"
(each01state01develops01a01nurse01practice01act,01which01defines01scope01of01practice01f
or01nurses01in01that01state.01This01practice01act01is01available01on01the01board01of01nursi
ng01website01for01each01state.)
A01nurse01is01planning01care01to01prevent01a01catheter-
related01bloodstream01infection01for01a01client01who01is01receiving01IV01fluid01therapy.01
Which01of01the01following01interventions01should01the01nurse01include01in01the01plan?01-
01answer--Perform01hand01hygiene01before01touching01the01IV01tubing.
(The01nurse01should01perform01thorough01hand01hygiene01before01touching01any01part01
of01the01infusion01system01or01the01client01to01reduce01the01risk01of01catheter-
related01blood01stream01infections.)
A01nurse01is01creating01a01plan01of01care01for01a01client01who01is01non-
ambulatory01and01has01bladder01and01bowel01incontinence.01Which01of01the01following01
interventions01should01the01nurse01include01to01prevent01skin01breakdown?01-01answer--
Offer01the01client01a01glass01of01water01every01two01hour01when01repositioning.
(The01nurse01should01offer01the01client01a01glass01of01water01every01two01hours01on01the
01clients01repositioning01schedule.01This01helps01prevent01dehydration,01which01increase
s01the01risk01of01skin01breakdown.)
,A01nurse01is01teaching01a01young01adult01female01client01about01health01screening01for01
breast01cancer.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01breast01self-examination01(BSE)?01-
01answer--"I01should01expect01to01feel01a01firm01ridge01along01the01bottom01curve01of01ea
ch01breast."
(The01nurse01should01instruct01the01client01at01a01firm01ridge01is01expected01along01the01
bottom01curve01of01each01breast.01The01client01should01be01able01to01feel01this01area01d
uring01the01BSE.01Performing01a01BSE01promotes01breast01self01awareness01so01that01t
he01client01knows01how01her01breast01normally01feel.01The01awareness01increases01the0
1clients01ability01to01identify01changes01that01require01further01evaluation.)
A01nurse01is01caring01for01an01adolescent01who01is01in01critical01condition01following01a01
motor01vehicle01crash01which01he01was01the01passenger.01The01clients01parent01shout01
at01the01nurse,01asking01why01her01son01is01dying01instead01of01the01driver.01Which01of01
the01following01actions01should01the01nurse01take01to01provide01emotional01support01to01t
he01parent?01-01answer--
Inform01the01parent01that01anger01is01a01natural01response01when01dealing01with01loss.
(The01nurse01should01identify01that01the01parent01is01in01the01anger01stage01of01grief.01T
he01nurse01should01assist01the01parent01to01understand01that01anger01is01a01natural01res
ponse01to01loss01and01encourage01her01to01talk01about01her01feelings.)
A01nurse01is01teaching01an01older01adult01client01about01accessing01electronic01resource
s01for01healthcare01information01on01the01internet.01Which01of01the01following01statement
s01should01the01nurse01include01in01the01teaching?01-
01answer--"Websites01ending01in01'.gov'01are01reliable01sites01for01obtaining01health01info
rmation01from01government01agencies."
(The01nurse01should01teach01the01client01how01to01select01reliable01internet01websites01
when01researching01health01care01information.01The01nurse01should01identify01that01web
sites01ending01in01'.gov'01and01'.edu'01are01considered01reliable01and01credible01sources0
1for01health01information.01Websites01ending01in01'.com'01should01not01be01used01for01re
searching01credible01healthcare01information.)
A01nurse01enters01a01clients01room01and01finds01the01client01lying01on01the01floor.01The01
client01states01that01on01the01way01to01the01bathroom01her01"knee01locked,"01causing01h
er01to01fall.01Which01of01the01following01actions01should01the01nurse01take01first?01-
01answer--Check01the01client01for01injuries.
(The01first01action01the01nurse01should01take01when01using01the01nursing01process01is01t
o01assess01the01client.01The01nurse01should01first01check01the01client01for01injuries01and0
1measure01vital01signs01to01help01determine01physiologic01stability.01The01nurse01should
01also01inform01the01provider01of01the01clients01fall01and01of01the01assessment01findings.)
A01nurse01is01teaching01a01client01who01has01rheumatoid01arthritis01about01chronic01pain
01management.01Which01of01the01following01statements01by01the01client01indicates01an01
understanding01of01the01teaching?01-
01answer--"I01should01use01a01warm01paraffin01dip01for01my01hands01and01feet."
, (The01nurse01should01instruct01the01client01to01dip01her01hands01and01feet01in01warm01pa
raffin01to01alleviate01pain01and01stiffness.01The01client01can01more01easily01perform01han
d01and01finger01exercises01following01the01treatment.)
A01community01health01nurse01is01planning01prevention01strategies01for01hypertension01
among01members01of01her01community.01The01nurse01should01identify01that01which01of01
the01following01ethnic01groups01in01the01community01is01at01greatest01risk01of01developin
g01hypertension?01-01answer--African01American
(Evidence-
based01practice01indicates01that01individuals01of01AA01ethnicity01have01the01highest01pre
valence01of01hypertension.01Therefore,01the01nurse01should01identify01community01mem
bers01of01this01ethnicity01are01at01greatest01risk01of01developing01hypertension.)
A01nurse01is01preparing01to01extinguish01a01small01fire01in01a01clients01room.01Which01of0
1the01following01actions01should01the01nurse01take01when01using01the01fire01extinguisher
?01-01answer--Slide01the01pin01on01top01of01the01fire01extinguisher01straight01out.
(The01nurse01should01pull01the01pin01on01top01of01the01fire01extinguisher01to01allow01for01
use01to01extinguish01the01fire.)
A01nurse01is01preparing01to01administer01intermittent01external01nutrition01via01a01clients0
1NG01tube.01In01which01order01should01the01nurse01take01the01following01actions?01-
01answer--1.01Assist01the01client01to01an01upright01position.
2.01Aspirate01501mL01of01gastric01contents.
3.01Test01the01pH01of01gastric01aspirate.
4.01Measure01gastric01residual01volume.
5.01Flush01the01NG01tube01with013001mL01of01water.
(First,01the01nurse01should01assist01the01client01into01high01Fowler's01position01or01raise0
1the01HOB01at01least013001degrees01to01help01prevent01aspiration.01Then,01the01nurse01s
hould01verify01the01tubes01placement01by01aspirating01501mL01of01gastric01contents01and
01then01testing01the01pH.01Then,01the01nurse01should01check01for01gastric01residual01volu
me.01Excessive01GRV01is01an01indication01of01delayed01gastric01emptying,01which01plac
es01the01client01at01risk01of01aspiration01if01additional01formula01is01given.01Finally,01the01
nurse01should01flush01the01tubing01with013001mL01of01water01to01ensure01the01tube01is01c
lear01and01patent.)
A01nurse01is01caring01for01a0147-year-
old01female01client01who01had01urinary01incontinence.01Which01of01the01following01action
s01should01the01nurse01take01first?01-01answer--
Obtain01a01specimen01from01the01client01for01culture.
(The01first01action01the01nurse01should01take01when01using01the01nursing01process01is01a
ssessment.01The01nurse01should01obtain01a01urine01specimen01from01the01client01to01rul
e01out01a01UTI.01If01it01is01a01determined01the01client01has01RBC's01and01WBC's01in01the0
1urine,01the01specimen01will01require01a01culture.01If01it01is01determined01that01the01client
01has01a01UTI,01this01will01require01treatment01before01any01further01assessment01of01inc
ontinence01would01be01indicated.)
