ATI Review Model-Fundamentals For Nursing 11th Edition
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1. A nurse is caring for a client who has a prescription for a clear liquid diet following
abdominal surgery. Which of the following items should the nurse include on the client's
tray?
A. Vanilla custard
B. Apple juice
C. Cream of wheat
D. Plain yogurt
Apple juice is a transparent liquid at room temperature and is appropriate for a clear liquid
diet, making it safe for immediate postoperative progression.
2. A nurse is assessing an older adult client who is admitted for confusion and lethargy. The
client's family reports a sudden change in behavior over the past 24 hours. Which of the
following conditions should the nurse suspect first?
A. Dementia
B. Urinary tract infection
C. Major depressive disorder
D. Parkinson's disease
Acute onset confusion in an older adult is a classic clinical manifestation of a urinary tract
infection, which frequently presents atypically without localized dysuria.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which
of the following muscle sites is the preferred and safest choice to prevent injury to the
sciatic nerve?
A. Dorsogluteal
B. Rectus femoris
C. Ventrogluteal
D. Vastus lateralis
The ventrogluteal site is free of major blood vessels and nerves, making it the safest and most
recommended site for adult intramuscular injections.
,4. A nurse is measuring the vital signs of a client who has a history of hypertension. The
client's blood pressure is 154/98 mm Hg. Which of the following actions should the nurse
take first?
A. Administer a prescribed as-needed antihypertensive medication immediately
B. Document the finding in the client's electronic health record and notify the provider
C. Recheck the client's blood pressure manually in 5 minutes using the appropriate cuff
size
D. Tell the client to lie down and remain undisturbed for one hour
Initial elevated single blood pressure readings require re-verification using a manual cuff of
correct size to ensure accuracy before clinical intervention.
5. A nurse is planning care for a client who is immobile and at high risk for pressure injury
development. Which of the following interventions should the nurse include in the plan of
care?
A. Massage bony prominences during every shift assessment
B. Reposition the client every 4 hours while in bed
C. Keep the head of the bed elevated at 45 degrees continuously
D. Use a dual-action silicone foam dressing on high-risk bony prominences
Prophylactic dressings like silicone foams help reduce shear and friction forces on high-risk
bony prominences, aiding in pressure injury prevention.
6. A nurse is assisting a client with ambulation using a walker for the first time. Which of
the following instructions should the nurse provide to the client?
A. Move the walker forward about 12 inches, then step forward with your stronger leg first
B. Lift the walker completely off the ground and push it forward while walking
C. Step forward with your weaker leg first into the center of the walker, followed by your
stronger leg
D. Lean heavily on the handgrips of the walker while advancing your feet
Clients should step forward with the weaker leg first into the walker frame, utilizing the
device for support before bringing the stronger leg forward.
7. A nurse is collecting data from a client who reports severe pain. Which of the following
pain assessment methods is the most reliable indicator of the client's pain intensity?
A. The nurse's objective observation of guarding and grimacing behaviors
B. The client's self-report using a validated pain rating scale
C. The client's physiological vital sign parameters including heart rate and blood pressure
D. Family members' descriptions of the client's typical pain tolerance
,Pain is a subjective experience, and the client's self-report is universally recognized as the
single most reliable indicator of pain intensity.
8. A nurse is preparing to administer medication through a nasogastric (NG) tube
connected to continuous wall suction. Which of the following actions should the nurse
perform immediately after medication administration?
A. Flush the NG tube with 30 mL of sterile water and reconnect suction immediately
B. Clamp the NG tube for 30 minutes to allow for medication absorption before reconnecting
suction
C. Instill 10 mL of air into the blue vent lumen of the NG tube
D. Increase the suction setting to high to clear any remaining medication from the tubing
Clamping the NG tube for 30 minutes prevents immediate aspiration of the administered
medication by the active wall suction.
9. A nurse is caring for a client who has a prescription for a 24-hour urine collection.
Which of the following actions should the nurse take during the collection process?
A. Save the very first voiding of the 24-hour period to establish a baseline volume
B. Keep the urine specimen container at room temperature in the client's bathroom
C. Discard the first voiding, then start the timing and collect all subsequent urine
D. Add the client's overnight urine output to a separate container for clinical comparison
A 24-hour urine collection starts with an empty bladder; the initial voiding is discarded, and
all subsequent urine is collected for the specified duration.
10. A nurse is reviewing infection control principles with a newly licensed nurse. Which of
the following actions represents the primary mechanism to prevent healthcare-associated
infections?
A. Wearing sterile gloves during any direct client care activity
B. Performing hand hygiene before and after every client contact
C. Changing intravenous site dressings every 24 hours without exception
D. Administering prophylactic broad-spectrum antibiotics to high-risk clients
Hand hygiene is universally acknowledged by infection control standards as the single most
effective intervention to interrupt the chain of infection.
11. A nurse is evaluating a client's understanding of a low-sodium diet for heart failure
management. Which of the following statements by the client indicates an understanding of
the teaching?
A. I can use as much sea salt as I want because it is natural
B. I will avoid canned soups and processed luncheon meats
, C. I should use baking soda liberally to season my food
D. I can eat frozen dinners as long as they do not contain red meat
Canned soups and processed meats contain extremely high levels of hidden sodium used for
preservation, which must be avoided by heart failure clients.
12. A nurse is caring for a client who is receiving continuous enteral tube feedings via a
gastrostomy tube. Which of the following actions should the nurse take to minimize the risk
of aspiration?
A. Elevate the head of the bed to at least 30 to 45 degrees during and for 1 hour after
feedings
B. Lie the client flat on their back every 4 hours to check residual volume accurately
C. Dilute the enteral formula with sterile water prior to administration
D. Administer the formula as a rapid bolus infusion rather than a continuous drip
Keeping the head of the bed elevated at 30 to 45 degrees utilizes gravity to prevent gastric
reflux and subsequent pulmonary aspiration of tube feeding formula.
13. A nurse is preparing to administer an intradermal injection for a tuberculin skin test.
Which of the following angles of insertion should the nurse use?
A. 15 degrees with the bevel facing upward
B. 45 degrees with the bevel facing downward
C. 90 degrees with the bevel facing sideways
D. 30 degrees with the bevel facing downward
Intradermal injections require a shallow insertion angle of 5 to 15 degrees with the needle
bevel pointed upward to deposit medication into the dermal layer.
14. A nurse is caring for a client who has a prescription for bed rest. The nurse notes
redness over the client's sacrum that does not blanch when fingertip pressure is applied.
How should the nurse stage this pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
A stage 1 pressure injury is characterized by intact skin with localized area of non-blanching
erythema, which may appear differently in darkly pigmented skin.
15. A nurse is assessing a client's respiratory status and notes a respiratory rate of 28/min,
shallow breathing, and use of accessory muscles. Which of the following terms should the
nurse use to document this breathing pattern?
Exam Testbank| Content Mastery Test | All Questions And
Answers 2026/2027 | Verified Answers Plus Rationales |
Graded Q&A Comprehensive Study Guide | Verified Latest
2027
1. A nurse is caring for a client who has a prescription for a clear liquid diet following
abdominal surgery. Which of the following items should the nurse include on the client's
tray?
A. Vanilla custard
B. Apple juice
C. Cream of wheat
D. Plain yogurt
Apple juice is a transparent liquid at room temperature and is appropriate for a clear liquid
diet, making it safe for immediate postoperative progression.
2. A nurse is assessing an older adult client who is admitted for confusion and lethargy. The
client's family reports a sudden change in behavior over the past 24 hours. Which of the
following conditions should the nurse suspect first?
A. Dementia
B. Urinary tract infection
C. Major depressive disorder
D. Parkinson's disease
Acute onset confusion in an older adult is a classic clinical manifestation of a urinary tract
infection, which frequently presents atypically without localized dysuria.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which
of the following muscle sites is the preferred and safest choice to prevent injury to the
sciatic nerve?
A. Dorsogluteal
B. Rectus femoris
C. Ventrogluteal
D. Vastus lateralis
The ventrogluteal site is free of major blood vessels and nerves, making it the safest and most
recommended site for adult intramuscular injections.
,4. A nurse is measuring the vital signs of a client who has a history of hypertension. The
client's blood pressure is 154/98 mm Hg. Which of the following actions should the nurse
take first?
A. Administer a prescribed as-needed antihypertensive medication immediately
B. Document the finding in the client's electronic health record and notify the provider
C. Recheck the client's blood pressure manually in 5 minutes using the appropriate cuff
size
D. Tell the client to lie down and remain undisturbed for one hour
Initial elevated single blood pressure readings require re-verification using a manual cuff of
correct size to ensure accuracy before clinical intervention.
5. A nurse is planning care for a client who is immobile and at high risk for pressure injury
development. Which of the following interventions should the nurse include in the plan of
care?
A. Massage bony prominences during every shift assessment
B. Reposition the client every 4 hours while in bed
C. Keep the head of the bed elevated at 45 degrees continuously
D. Use a dual-action silicone foam dressing on high-risk bony prominences
Prophylactic dressings like silicone foams help reduce shear and friction forces on high-risk
bony prominences, aiding in pressure injury prevention.
6. A nurse is assisting a client with ambulation using a walker for the first time. Which of
the following instructions should the nurse provide to the client?
A. Move the walker forward about 12 inches, then step forward with your stronger leg first
B. Lift the walker completely off the ground and push it forward while walking
C. Step forward with your weaker leg first into the center of the walker, followed by your
stronger leg
D. Lean heavily on the handgrips of the walker while advancing your feet
Clients should step forward with the weaker leg first into the walker frame, utilizing the
device for support before bringing the stronger leg forward.
7. A nurse is collecting data from a client who reports severe pain. Which of the following
pain assessment methods is the most reliable indicator of the client's pain intensity?
A. The nurse's objective observation of guarding and grimacing behaviors
B. The client's self-report using a validated pain rating scale
C. The client's physiological vital sign parameters including heart rate and blood pressure
D. Family members' descriptions of the client's typical pain tolerance
,Pain is a subjective experience, and the client's self-report is universally recognized as the
single most reliable indicator of pain intensity.
8. A nurse is preparing to administer medication through a nasogastric (NG) tube
connected to continuous wall suction. Which of the following actions should the nurse
perform immediately after medication administration?
A. Flush the NG tube with 30 mL of sterile water and reconnect suction immediately
B. Clamp the NG tube for 30 minutes to allow for medication absorption before reconnecting
suction
C. Instill 10 mL of air into the blue vent lumen of the NG tube
D. Increase the suction setting to high to clear any remaining medication from the tubing
Clamping the NG tube for 30 minutes prevents immediate aspiration of the administered
medication by the active wall suction.
9. A nurse is caring for a client who has a prescription for a 24-hour urine collection.
Which of the following actions should the nurse take during the collection process?
A. Save the very first voiding of the 24-hour period to establish a baseline volume
B. Keep the urine specimen container at room temperature in the client's bathroom
C. Discard the first voiding, then start the timing and collect all subsequent urine
D. Add the client's overnight urine output to a separate container for clinical comparison
A 24-hour urine collection starts with an empty bladder; the initial voiding is discarded, and
all subsequent urine is collected for the specified duration.
10. A nurse is reviewing infection control principles with a newly licensed nurse. Which of
the following actions represents the primary mechanism to prevent healthcare-associated
infections?
A. Wearing sterile gloves during any direct client care activity
B. Performing hand hygiene before and after every client contact
C. Changing intravenous site dressings every 24 hours without exception
D. Administering prophylactic broad-spectrum antibiotics to high-risk clients
Hand hygiene is universally acknowledged by infection control standards as the single most
effective intervention to interrupt the chain of infection.
11. A nurse is evaluating a client's understanding of a low-sodium diet for heart failure
management. Which of the following statements by the client indicates an understanding of
the teaching?
A. I can use as much sea salt as I want because it is natural
B. I will avoid canned soups and processed luncheon meats
, C. I should use baking soda liberally to season my food
D. I can eat frozen dinners as long as they do not contain red meat
Canned soups and processed meats contain extremely high levels of hidden sodium used for
preservation, which must be avoided by heart failure clients.
12. A nurse is caring for a client who is receiving continuous enteral tube feedings via a
gastrostomy tube. Which of the following actions should the nurse take to minimize the risk
of aspiration?
A. Elevate the head of the bed to at least 30 to 45 degrees during and for 1 hour after
feedings
B. Lie the client flat on their back every 4 hours to check residual volume accurately
C. Dilute the enteral formula with sterile water prior to administration
D. Administer the formula as a rapid bolus infusion rather than a continuous drip
Keeping the head of the bed elevated at 30 to 45 degrees utilizes gravity to prevent gastric
reflux and subsequent pulmonary aspiration of tube feeding formula.
13. A nurse is preparing to administer an intradermal injection for a tuberculin skin test.
Which of the following angles of insertion should the nurse use?
A. 15 degrees with the bevel facing upward
B. 45 degrees with the bevel facing downward
C. 90 degrees with the bevel facing sideways
D. 30 degrees with the bevel facing downward
Intradermal injections require a shallow insertion angle of 5 to 15 degrees with the needle
bevel pointed upward to deposit medication into the dermal layer.
14. A nurse is caring for a client who has a prescription for bed rest. The nurse notes
redness over the client's sacrum that does not blanch when fingertip pressure is applied.
How should the nurse stage this pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
A stage 1 pressure injury is characterized by intact skin with localized area of non-blanching
erythema, which may appear differently in darkly pigmented skin.
15. A nurse is assessing a client's respiratory status and notes a respiratory rate of 28/min,
shallow breathing, and use of accessory muscles. Which of the following terms should the
nurse use to document this breathing pattern?
