ATI Proctored Exam
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving
IV fluid therapy. Which of the following interventions should the nurse include in the plan?
a. Change bags of IV solution every 72 hours.
b. Perform hand hygiene before touching IV tubing.
c. use hydrogen peroxide to cleanse IV insertion site.
d. Assess the IV insertion site every 12 hr for redness. - correct answer b. Perform hand hygiene before
touching IV tubing
Explanation: The nurse should perform thorough hand hygiene before touching any part of the infusion
system or the client to reduce the risk of catheter-related blood stream infections.
A newly licensed nurse asks a charge nurse where to find information about scope of practice for
registered nurses. Which of the following responses should the charge nurse make?
a. "The National Institutes of Health website contains this information."
b. "The state board of nursing can provide this information."
c. The facility's legal department write a summary of scope of practice."
d. "The Nurse Licensure Compact defines a nurse's scope of practice." - correct answer b. "The state
board of nursing can provide this information."
explanation: Each state develops a nurse practice act, which defines scope of practice for nurses in that
state. This practice act is available on the board of nursing website for each state.
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following
actions should the nurse take to treat the client's neuropathic pain?
a. inform the client that phantom limb pain is not real.
b. administer a beta-blocking medication to the client.
c. place the client on a soft mattress.
d. loosen the bandage on the client's residual limb. - correct answer b. administer a beta-blocking
medication to the client.
,ATI Proctored Exam
explanation: The nurse should administer a beta-blocking medication to the client. This classification of
medication has been shown to relieve the phantom limb pain manifestations of constant dull and
burning type pain.
A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel
incontinence. Which of the following interventions should the nurse include to prevent skin breakdown?
a. use a sheepskin device to pad the client's pressure points.
b. apply cornstarch to the perineal area after bathing the client.
c. massage the client's skin and pressure points every 12 hr.
d. offer the client a glass of water every 2 hr when re-positioning. - correct answer d. offer the client a
glass of water every 2 hr when re-positioning.
explanation: The nurse should offer the client a glass of water every 2 hr on the client's re-positioning
schedule. This helps prevent dehydration, which increases the risk of skin breakdown.
a nurse is teaching a young adult female client about health screening for breast cancer. Which of the
following statements by the client indicates an understanding of breast self-examination (BSE)?
a. "I should perform a BSE about 1 week before my period each month."
b. "I should use the fingers of my right hand to feel for lumps in my right breast."
c. "I should report a lump in my breast if it remains for two consecutive BSEs."
d. "I should expect to feel a firm ridge along the bottom curve of each breast." - correct answer d. "I
should expect to feel a firm ridge along the bottom curve of each breast."
explanation: The nurse should instruct the client that a firm ridge is expected along the bottom curve of
each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast
self-awareness so that the client knows how her breasts normally feel. This awareness increases the
client's ability to identify changes that require further evaluation and treatment.
A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in
which he is the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of
the driver. Which of the following actions should the nurse take to provide emotional support to the
parent?
a. encourage the parent to speak with the family of the driver of the car.
,ATI Proctored Exam
b. inform the parent that anger is a natural response when dealing with loss.
c. ask the parent to leave and come back later after she has calmed down.
d. contact a clergy member to come and speak with the parent. - correct answer b. inform the parent
that anger is a natural response when dealing with loss.
explanation: The nurse should identify that the parent is in the anger stage of grief. The nurse should
assist the parent to understand that anger is a natural response to loss and encourage her to talk about
her feelings.
A nurse is teaching an older adult client about accessing electronic resources for health care information
on the internet. Which of the following statements should the nurse include in the teaching?
a. "websites that are evidence-based avoid placing direct links to other evidence-based websites on
their home pages."
b. "Websites that market products are credible as long as the products are beneficial for health care."
c. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government
agencies."
d. "Website forums with the opinions of other clients provide factual and trustworthy information." -
correct answer c. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from
government agencies."
explanation: The nurse should teach the client how to select reliable internet websites when researching
health care information. The nurse should identify that websites ending in ".gov" (government agencies)
and ".edu" (educational organizations) are considered reliable and credible sources for health
information. Websites ending in ".com" should not be used for researching credible health care
information.
A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to
the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take
first?
a. ask an assistive personnel to help return the client to her bed.
b. complete an incident report.
c. check the client for injuries.
d. document objective detail about the client's condition in the medical record. - correct answer c. check
the client for injuries.
, ATI Proctored Exam
explanation: The first action the nurse should take when using the nursing process is to assess the client.
The nurse should first check the client for injuries and measure vital signs to help determine physiologic
stability. The nurse should also inform the provider of the client's fall and of the assessment findings
A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the
following statements by the client indicates and understanding of the teaching?
a. "I should stop participating in my bowling league."
b. "I should take a cool shower in the morning to relieve stiffness."
c. "I should decrease my intake of foods containing purine."
d. "I should use a warm paraffin dip for my hands and feet." - correct answer d. "I should use a warm
paraffin dip for my hands and feet."
explanation: The nurse should instruct the client to dip her hands and feet in warm paraffin to alleviate
pain and stiffness. The client can more easily perform hand and finger exercises following the treatment.
A community health nurse is planning prevention strategies for hypertension among members of her
community. The nurse should identify that which of the following ethnic groups in the community is at
greatest risk of developing hypertension?
a. african americans
b. hispanic americans
c. european americans
d. native americans - correct answer a. african americans
explanation: Evidence-based practice indicates that individuals of African-American ethnicity have the
highest prevalence of hypertension. Therefore, the nurse should identify community members of this
ethnicity are at greatest risk of developing hypertension
A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should
the nurse take when using the fire extinguisher?
a. aim the fire extinguisher at the top of the flames.
b. pump the handles of the fire extinguisher up and down three times.
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving
IV fluid therapy. Which of the following interventions should the nurse include in the plan?
a. Change bags of IV solution every 72 hours.
b. Perform hand hygiene before touching IV tubing.
c. use hydrogen peroxide to cleanse IV insertion site.
d. Assess the IV insertion site every 12 hr for redness. - correct answer b. Perform hand hygiene before
touching IV tubing
Explanation: The nurse should perform thorough hand hygiene before touching any part of the infusion
system or the client to reduce the risk of catheter-related blood stream infections.
A newly licensed nurse asks a charge nurse where to find information about scope of practice for
registered nurses. Which of the following responses should the charge nurse make?
a. "The National Institutes of Health website contains this information."
b. "The state board of nursing can provide this information."
c. The facility's legal department write a summary of scope of practice."
d. "The Nurse Licensure Compact defines a nurse's scope of practice." - correct answer b. "The state
board of nursing can provide this information."
explanation: Each state develops a nurse practice act, which defines scope of practice for nurses in that
state. This practice act is available on the board of nursing website for each state.
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following
actions should the nurse take to treat the client's neuropathic pain?
a. inform the client that phantom limb pain is not real.
b. administer a beta-blocking medication to the client.
c. place the client on a soft mattress.
d. loosen the bandage on the client's residual limb. - correct answer b. administer a beta-blocking
medication to the client.
,ATI Proctored Exam
explanation: The nurse should administer a beta-blocking medication to the client. This classification of
medication has been shown to relieve the phantom limb pain manifestations of constant dull and
burning type pain.
A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel
incontinence. Which of the following interventions should the nurse include to prevent skin breakdown?
a. use a sheepskin device to pad the client's pressure points.
b. apply cornstarch to the perineal area after bathing the client.
c. massage the client's skin and pressure points every 12 hr.
d. offer the client a glass of water every 2 hr when re-positioning. - correct answer d. offer the client a
glass of water every 2 hr when re-positioning.
explanation: The nurse should offer the client a glass of water every 2 hr on the client's re-positioning
schedule. This helps prevent dehydration, which increases the risk of skin breakdown.
a nurse is teaching a young adult female client about health screening for breast cancer. Which of the
following statements by the client indicates an understanding of breast self-examination (BSE)?
a. "I should perform a BSE about 1 week before my period each month."
b. "I should use the fingers of my right hand to feel for lumps in my right breast."
c. "I should report a lump in my breast if it remains for two consecutive BSEs."
d. "I should expect to feel a firm ridge along the bottom curve of each breast." - correct answer d. "I
should expect to feel a firm ridge along the bottom curve of each breast."
explanation: The nurse should instruct the client that a firm ridge is expected along the bottom curve of
each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast
self-awareness so that the client knows how her breasts normally feel. This awareness increases the
client's ability to identify changes that require further evaluation and treatment.
A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in
which he is the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of
the driver. Which of the following actions should the nurse take to provide emotional support to the
parent?
a. encourage the parent to speak with the family of the driver of the car.
,ATI Proctored Exam
b. inform the parent that anger is a natural response when dealing with loss.
c. ask the parent to leave and come back later after she has calmed down.
d. contact a clergy member to come and speak with the parent. - correct answer b. inform the parent
that anger is a natural response when dealing with loss.
explanation: The nurse should identify that the parent is in the anger stage of grief. The nurse should
assist the parent to understand that anger is a natural response to loss and encourage her to talk about
her feelings.
A nurse is teaching an older adult client about accessing electronic resources for health care information
on the internet. Which of the following statements should the nurse include in the teaching?
a. "websites that are evidence-based avoid placing direct links to other evidence-based websites on
their home pages."
b. "Websites that market products are credible as long as the products are beneficial for health care."
c. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government
agencies."
d. "Website forums with the opinions of other clients provide factual and trustworthy information." -
correct answer c. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from
government agencies."
explanation: The nurse should teach the client how to select reliable internet websites when researching
health care information. The nurse should identify that websites ending in ".gov" (government agencies)
and ".edu" (educational organizations) are considered reliable and credible sources for health
information. Websites ending in ".com" should not be used for researching credible health care
information.
A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to
the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take
first?
a. ask an assistive personnel to help return the client to her bed.
b. complete an incident report.
c. check the client for injuries.
d. document objective detail about the client's condition in the medical record. - correct answer c. check
the client for injuries.
, ATI Proctored Exam
explanation: The first action the nurse should take when using the nursing process is to assess the client.
The nurse should first check the client for injuries and measure vital signs to help determine physiologic
stability. The nurse should also inform the provider of the client's fall and of the assessment findings
A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the
following statements by the client indicates and understanding of the teaching?
a. "I should stop participating in my bowling league."
b. "I should take a cool shower in the morning to relieve stiffness."
c. "I should decrease my intake of foods containing purine."
d. "I should use a warm paraffin dip for my hands and feet." - correct answer d. "I should use a warm
paraffin dip for my hands and feet."
explanation: The nurse should instruct the client to dip her hands and feet in warm paraffin to alleviate
pain and stiffness. The client can more easily perform hand and finger exercises following the treatment.
A community health nurse is planning prevention strategies for hypertension among members of her
community. The nurse should identify that which of the following ethnic groups in the community is at
greatest risk of developing hypertension?
a. african americans
b. hispanic americans
c. european americans
d. native americans - correct answer a. african americans
explanation: Evidence-based practice indicates that individuals of African-American ethnicity have the
highest prevalence of hypertension. Therefore, the nurse should identify community members of this
ethnicity are at greatest risk of developing hypertension
A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should
the nurse take when using the fire extinguisher?
a. aim the fire extinguisher at the top of the flames.
b. pump the handles of the fire extinguisher up and down three times.
