ATI RN Fundamentals Proctored Exam-
100% Correct Answers -Latest Update
The greatest risk to a client w/a low platelet count is injury that results in bleeding,
obtaining a temp this way increases the risk for bleeding.
A nurse is instructing a group of nursing students in measuring a client's RR. Which of
the following guidelines should the nurse include? Select all.
A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
D. Count the rate for 1 min if it is regular
E. Count & report any signs the client demonstrates - CORRECT ANSWERS-A, B, C
For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't
need to be reported
A nurse who is admitting a client who has a fractured femur obtains a BP reading of
140/94 mmHg. The client denies any history of HTN. Which of the following actions
should the nurse take next?
A. Request a prescription for an antihypertensive med
B. Ask the client if she is having pain
C. Request a prescription for an anti-anxiety med
D. Return in 30min to recheck the client's BP - CORRECT ANSWERS-B
Perform a pain assessment would be the appropriate action to take next
A nurse is performing an admission assessment on a client. When measuring her vital
signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse
rate is 84/min. What is the client's pulse deficit? - CORRECT ANSWERS-16/min
the pulse deficit is the difference between the apical & radial pulse rates.
84-68=16
A nurse is caring for a client who will perform fecal occult blood testing at home. Which
of the following info should the nurse include when explaining the procedure to the
client?
A. Eating more protein is optimal prior to testing
B. One stool specimen is sufficient for testing
C. A red color change indicates a positive test
D. The specimen cannot be contaminated - CORRECT ANSWERS-D.
,The stool specimens cannot be contaminated with water or urine
A nurse is talking w/a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the
nurse recommend?
A. Macaroni & cheese
B. Fresh fruit & whole wheat toast
C. Rice pudding & ripe bananas
D. Roast chicken & white rice - CORRECT ANSWERS-B.
A high-fiber diet promotes normal bowel elimination
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing
the client, the nurse should expect which of the following findings? Select all.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema - CORRECT ANSWERS-B, C, D
fever=caused by dehydration
tachycardia not brady
hypotension because of decreased BP from dehydration
fluid overload=peripheral edema
A nurse is preparing to administer a cleansing enema to an adult client in preparation
for a diagnostic procedure. Which of the following are appropriate steps for the nurse to
take? Select all.
A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches above the client's anus - CORRECT
ANSWERS-A, B, C
-D is the appropriate length of insertion for a child, 3-4 for an adult.
-24 inches is too high & will cause it to run to fast & possible painful distention of the
colon, 18 inches is the recommended height
Can an RN delegate to the LPN to provide tracheostomy care to a client with
pneumonia? - CORRECT ANSWERS-Yes.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients.
Which of the following client's needs may the nurse assign to an assistive personnel
(AP)?
, A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer - CORRECT ANSWERS-C.
Reapplying a condom catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that
the nurse may delegate to the AP
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago
to an AP. Which of the following information should the nurse share with the AP? Select
All.
A. The roommate is up independently.
B. The client ambulates w/his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning - CORRECT ANSWERS-B, C, D
An RN is making assignments for client care to a LPN at the beginning of the shift.
Which of the following assignments should the LPN question?
A. Assisting a client who is 24hr postop to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the
previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump - CORRECT ANSWERS-D.
Replacing the cartridge and tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
A nurse is preparing an in-service program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation? Select all.
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances - CORRECT ANSWERS-B, C, E
A and D are rights of medication administration
100% Correct Answers -Latest Update
The greatest risk to a client w/a low platelet count is injury that results in bleeding,
obtaining a temp this way increases the risk for bleeding.
A nurse is instructing a group of nursing students in measuring a client's RR. Which of
the following guidelines should the nurse include? Select all.
A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen
C. Observe 1 full respiratory cycle before counting the rate
D. Count the rate for 1 min if it is regular
E. Count & report any signs the client demonstrates - CORRECT ANSWERS-A, B, C
For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't
need to be reported
A nurse who is admitting a client who has a fractured femur obtains a BP reading of
140/94 mmHg. The client denies any history of HTN. Which of the following actions
should the nurse take next?
A. Request a prescription for an antihypertensive med
B. Ask the client if she is having pain
C. Request a prescription for an anti-anxiety med
D. Return in 30min to recheck the client's BP - CORRECT ANSWERS-B
Perform a pain assessment would be the appropriate action to take next
A nurse is performing an admission assessment on a client. When measuring her vital
signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse
rate is 84/min. What is the client's pulse deficit? - CORRECT ANSWERS-16/min
the pulse deficit is the difference between the apical & radial pulse rates.
84-68=16
A nurse is caring for a client who will perform fecal occult blood testing at home. Which
of the following info should the nurse include when explaining the procedure to the
client?
A. Eating more protein is optimal prior to testing
B. One stool specimen is sufficient for testing
C. A red color change indicates a positive test
D. The specimen cannot be contaminated - CORRECT ANSWERS-D.
,The stool specimens cannot be contaminated with water or urine
A nurse is talking w/a client who reports constipation. When the nurse discusses dietary
changes that can help prevent constipation, which of the following foods should the
nurse recommend?
A. Macaroni & cheese
B. Fresh fruit & whole wheat toast
C. Rice pudding & ripe bananas
D. Roast chicken & white rice - CORRECT ANSWERS-B.
A high-fiber diet promotes normal bowel elimination
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing
the client, the nurse should expect which of the following findings? Select all.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema - CORRECT ANSWERS-B, C, D
fever=caused by dehydration
tachycardia not brady
hypotension because of decreased BP from dehydration
fluid overload=peripheral edema
A nurse is preparing to administer a cleansing enema to an adult client in preparation
for a diagnostic procedure. Which of the following are appropriate steps for the nurse to
take? Select all.
A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches above the client's anus - CORRECT
ANSWERS-A, B, C
-D is the appropriate length of insertion for a child, 3-4 for an adult.
-24 inches is too high & will cause it to run to fast & possible painful distention of the
colon, 18 inches is the recommended height
Can an RN delegate to the LPN to provide tracheostomy care to a client with
pneumonia? - CORRECT ANSWERS-Yes.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients.
Which of the following client's needs may the nurse assign to an assistive personnel
(AP)?
, A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer - CORRECT ANSWERS-C.
Reapplying a condom catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that
the nurse may delegate to the AP
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago
to an AP. Which of the following information should the nurse share with the AP? Select
All.
A. The roommate is up independently.
B. The client ambulates w/his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning - CORRECT ANSWERS-B, C, D
An RN is making assignments for client care to a LPN at the beginning of the shift.
Which of the following assignments should the LPN question?
A. Assisting a client who is 24hr postop to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the
previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump - CORRECT ANSWERS-D.
Replacing the cartridge and tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
A nurse is preparing an in-service program about delegation. Which of the following
elements should she identify when presenting the 5 rights of delegation? Select all.
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances - CORRECT ANSWERS-B, C, E
A and D are rights of medication administration
