ATI FUNDAMENTALS NURSING, NURSING FUNDAMENTALS STUDY
GUIDE, PATIENT SAFETY NURSING ATI, INFECTION CONTROL
NURSING REVIEW, VITAL SIGNS NURSING BASICS, THERAPEUTIC
COMMUNICATION NURSING, MOBILITY NURSING CARE, BASIC
NURSING SKILLS NOTES, CLINICAL FUNDAMENTA
Nursing Fundamentals & Basic Concepts
1. Which action is the nurse's priority when receiving a newly admitted client?
A. Complete the admission paperwork
B. Assess the client's airway and breathing
C. Obtain the client's dietary preferences
D. Orient the client to the television
Answer: B
Rationale: Airway and breathing are immediate priorities according to the ABC approach.
2. Which nursing action best demonstrates patient-centered care?
A. Making decisions without consulting the client
B. Following the same care plan for every client
C. Incorporating the client's preferences into the plan of care
D. Asking the family to make all decisions
Answer: C
Rationale: Patient-centered care respects individual preferences, values, needs, and goals.
3. Which phase of the nursing process involves collecting subjective and objective
information?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: A
Rationale: Assessment involves systematic collection of information about the client's health
status.
4. Which finding is considered subjective data?
A. Blood pressure of 140/88 mm Hg
B. Temperature of 38.2°C
,C. Client reports feeling nauseated
D. Oxygen saturation of 95%
Answer: C
Rationale: Subjective data are symptoms or information reported by the client.
5. Which finding is objective data?
A. "I feel dizzy."
B. "My pain is severe."
C. "I feel anxious."
D. Respiratory rate of 24/min
Answer: D
Rationale: Objective data are measurable or observable findings.
6. What is the primary purpose of a nursing diagnosis?
A. Identify a medical disease
B. Describe the client's response to a health condition
C. Determine the physician's treatment
D. Establish the hospital's billing code
Answer: B
Rationale: Nursing diagnoses identify human responses to actual or potential health problems
that nurses can address.
7. Which goal is written appropriately for a nursing care plan?
A. Client will feel better.
B. Client will improve soon.
C. Client will maintain oxygen saturation above the prescribed target during the shift.
D. Nurse will monitor oxygen saturation.
Answer: C
Rationale: An appropriate goal is specific and measurable and describes the expected client
outcome.
8. During evaluation, the nurse determines that a goal was not achieved. What should the
nurse do?
A. Ignore the finding
B. Discontinue all interventions
C. Reassess the client and modify the plan as needed
D. Document the goal as met
,Answer: C
Rationale: Failure to achieve a goal requires reassessment and possible modification of
interventions.
9. Which action demonstrates clinical judgment?
A. Performing every task in the same order
B. Recognizing a change in condition and determining an appropriate response
C. Waiting for another nurse to notice abnormal findings
D. Avoiding communication with the provider
Answer: B
Rationale: Clinical judgment involves recognizing relevant findings, interpreting them, and
deciding on appropriate action.
10. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting sudden difficulty breathing
C. Client requesting a meal
D. Client asking when discharge will occur
Answer: B
Rationale: Sudden difficulty breathing threatens airway and oxygenation and requires
immediate assessment.
Vital Signs & Assessment
11. Which temperature route is generally considered contraindicated in a client who recently
underwent rectal surgery?
A. Oral
B. Axillary
C. Temporal
D. Rectal
Answer: D
Rationale: Rectal temperature measurement can injure tissue or cause bleeding after rectal
surgery.
12. Which pulse site is commonly used when assessing an adult's routine peripheral pulse?
A. Radial
B. Carotid
, C. Femoral
D. Apical
Answer: A
Rationale: The radial pulse is readily accessible and commonly used for routine assessment in
adults.
13. A nurse counts 18 respirations in 30 seconds. What is the respiratory rate?
A. 18/min
B. 24/min
C. 36/min
D. 54/min
Answer: C
Rationale: Eighteen respirations in 30 seconds equals 36 respirations per minute.
14. Which respiratory finding requires further assessment?
A. Regular respirations at 16/min
B. Symmetrical chest movement
C. Use of accessory muscles at rest
D. Quiet, effortless breathing
Answer: C
Rationale: Accessory muscle use at rest can indicate increased work of breathing.
15. Which blood pressure finding should the nurse recognize as requiring follow-up?
A. A reading within the client's usual range
B. A significantly lower reading accompanied by dizziness
C. A reading obtained after the client rested
D. A reading from the correct cuff size
Answer: B
Rationale: Hypotension accompanied by symptoms can indicate inadequate perfusion and
requires assessment.
16. Which cuff selection is appropriate for blood pressure measurement?
A. Cuff that is too small
B. Cuff that is appropriately sized for the client's arm
C. Pediatric cuff for every adult
D. Any cuff regardless of arm circumference
Answer: B
Rationale: Proper cuff size is necessary for accurate blood pressure measurement.
GUIDE, PATIENT SAFETY NURSING ATI, INFECTION CONTROL
NURSING REVIEW, VITAL SIGNS NURSING BASICS, THERAPEUTIC
COMMUNICATION NURSING, MOBILITY NURSING CARE, BASIC
NURSING SKILLS NOTES, CLINICAL FUNDAMENTA
Nursing Fundamentals & Basic Concepts
1. Which action is the nurse's priority when receiving a newly admitted client?
A. Complete the admission paperwork
B. Assess the client's airway and breathing
C. Obtain the client's dietary preferences
D. Orient the client to the television
Answer: B
Rationale: Airway and breathing are immediate priorities according to the ABC approach.
2. Which nursing action best demonstrates patient-centered care?
A. Making decisions without consulting the client
B. Following the same care plan for every client
C. Incorporating the client's preferences into the plan of care
D. Asking the family to make all decisions
Answer: C
Rationale: Patient-centered care respects individual preferences, values, needs, and goals.
3. Which phase of the nursing process involves collecting subjective and objective
information?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: A
Rationale: Assessment involves systematic collection of information about the client's health
status.
4. Which finding is considered subjective data?
A. Blood pressure of 140/88 mm Hg
B. Temperature of 38.2°C
,C. Client reports feeling nauseated
D. Oxygen saturation of 95%
Answer: C
Rationale: Subjective data are symptoms or information reported by the client.
5. Which finding is objective data?
A. "I feel dizzy."
B. "My pain is severe."
C. "I feel anxious."
D. Respiratory rate of 24/min
Answer: D
Rationale: Objective data are measurable or observable findings.
6. What is the primary purpose of a nursing diagnosis?
A. Identify a medical disease
B. Describe the client's response to a health condition
C. Determine the physician's treatment
D. Establish the hospital's billing code
Answer: B
Rationale: Nursing diagnoses identify human responses to actual or potential health problems
that nurses can address.
7. Which goal is written appropriately for a nursing care plan?
A. Client will feel better.
B. Client will improve soon.
C. Client will maintain oxygen saturation above the prescribed target during the shift.
D. Nurse will monitor oxygen saturation.
Answer: C
Rationale: An appropriate goal is specific and measurable and describes the expected client
outcome.
8. During evaluation, the nurse determines that a goal was not achieved. What should the
nurse do?
A. Ignore the finding
B. Discontinue all interventions
C. Reassess the client and modify the plan as needed
D. Document the goal as met
,Answer: C
Rationale: Failure to achieve a goal requires reassessment and possible modification of
interventions.
9. Which action demonstrates clinical judgment?
A. Performing every task in the same order
B. Recognizing a change in condition and determining an appropriate response
C. Waiting for another nurse to notice abnormal findings
D. Avoiding communication with the provider
Answer: B
Rationale: Clinical judgment involves recognizing relevant findings, interpreting them, and
deciding on appropriate action.
10. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting sudden difficulty breathing
C. Client requesting a meal
D. Client asking when discharge will occur
Answer: B
Rationale: Sudden difficulty breathing threatens airway and oxygenation and requires
immediate assessment.
Vital Signs & Assessment
11. Which temperature route is generally considered contraindicated in a client who recently
underwent rectal surgery?
A. Oral
B. Axillary
C. Temporal
D. Rectal
Answer: D
Rationale: Rectal temperature measurement can injure tissue or cause bleeding after rectal
surgery.
12. Which pulse site is commonly used when assessing an adult's routine peripheral pulse?
A. Radial
B. Carotid
, C. Femoral
D. Apical
Answer: A
Rationale: The radial pulse is readily accessible and commonly used for routine assessment in
adults.
13. A nurse counts 18 respirations in 30 seconds. What is the respiratory rate?
A. 18/min
B. 24/min
C. 36/min
D. 54/min
Answer: C
Rationale: Eighteen respirations in 30 seconds equals 36 respirations per minute.
14. Which respiratory finding requires further assessment?
A. Regular respirations at 16/min
B. Symmetrical chest movement
C. Use of accessory muscles at rest
D. Quiet, effortless breathing
Answer: C
Rationale: Accessory muscle use at rest can indicate increased work of breathing.
15. Which blood pressure finding should the nurse recognize as requiring follow-up?
A. A reading within the client's usual range
B. A significantly lower reading accompanied by dizziness
C. A reading obtained after the client rested
D. A reading from the correct cuff size
Answer: B
Rationale: Hypotension accompanied by symptoms can indicate inadequate perfusion and
requires assessment.
16. Which cuff selection is appropriate for blood pressure measurement?
A. Cuff that is too small
B. Cuff that is appropriately sized for the client's arm
C. Pediatric cuff for every adult
D. Any cuff regardless of arm circumference
Answer: B
Rationale: Proper cuff size is necessary for accurate blood pressure measurement.
