ATI RN Concept Based
Assessment Level 1
A nurse in a long-term care facility discovers a small fire in a client's trash can. After
moving the client to safety, which of the following actions should the nurse take next? -
Answer: Pull the alarm to notify emergency services.
(Evidence-based practice indicates the nurse should first rescue and remove clients in
immediate danger and then activate the alarm to notify authorities of the situation.)
A nurse is preparing to leave the room who is on isolation precautions. Which of the
following actions should the nurse take when removing a tied surgical mask? -Answer:
Remove the mask by securely holding the ties and moving it away from the face.
(The nurse should untie the bottom strings and then the top strings. Finally, while still
holding the strings, the nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which is contaminated.)
A nurse is searching electronic databases for clinical research about behavioral
indicators. Which of the following online sources should the nurse select to research this
infant care issue? -Answer: Cumulative Index to Nursing and Allied Health Literature
(CINAHL)
(The nurse should select the Cumulative Index to Nursing and Allied Health Literature
(CINAHL) to locate clinical research about health-related client care issues. CINAHL is
a cumulative index that the nurse can search electronically to locate reliable data related
to the specific topic being researched.)
A nurse is preparing to administer three medications to a client who has an NG tube: a
levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -Answer: Crush the
levothyroxine tablet into a powder and dissolve it into 30 mL of warm sterile water.
(The nurse should prepare simple tablets for NG administration by crushing them into a
fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can
cause discomfort. Sterile water eliminates the possible problem of chemicals in tap
water interacting with the medication.)
A nurse is planning care who has an indwelling urinary catheter. Which of the following
interventions include in the plan to prevent the development of a catheter-associated
urinary tract infection (CAUTI)? -Answer: Secure the catheter tubing to the client's leg.
(The nurse should assess the client's need for urinary catheterization and should follow
evidence-based practice to prevent or reduce the risk of CAUTI development. This
includes securing the catheter tubing to the client's leg so that the catheter does not
move, reducing the risk of urethral trauma and introduction of bacteria into the urinary
system.)
,A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of
the following pain scales should the nurse use to access the toddler's pain level? -
Answer: FLACC scale
(The nurse should use the FLACC scale to assess pain for a 2-year-old child. The FLACC
scale assesses facial expression, leg movement, activity, cry, and consolability in
children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.)
A nurse is caring for a client who has cancer and is planning discharge to home with
hospice care. Which of the following statements by the client indicates that he is
experiencing spiritual distress? -Answer: "I wish God had not allowed this cancer to
invade my body."
(The nurse should identify that this statement indicates the client is experiencing
spiritual distress, which occurs when there is a disturbance in a client's belief system.
This client is expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer and is scheduled for
chemotherapy. The client reports experiencing chemotherapy-induced nausea and
vomiting (CINV) during her previous round of treatment. Which of the following
interventions should the nurse include in the client's plan of care? -Answer:
Administer ondansetron to the client prior to chemotherapy administration.
(The nurse should incorporate evidence-based practice interventions into the client's
plan of care to prevent and treat CINV. Evidence-based research indicates that
prevention of CINV is best achieved when antiemetics, such as ondansetron, are given
prior to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client following a brief stay in
acute care. In adherence with the Joint Commission National Patient Safety Goals
regarding medication administration, which of the following actions should the nurse
take? -Answer: Compare a list of the client's current medications with the ones he will
take in long-term care.
(The Joint Commission National Patient Safety Goals regarding medication
reconciliation includes maintaining and communicating accurate client medication
information. The nurse should complete a medication reconciliation to identify and
resolve any discrepancies by comparing the client's list of current medications with the
medications he will take in the long-term care facility and addressing any duplications,
omissions, or interactions.)
A nurse in a long-term care facility is performing a fall risk assessment on a newly
admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod
cane for ambulation. Which of the following actions should the nurse take when using
this test? -Answer: Observe the client ambulating a distance of 3 m (10 feet) during the
TUG test.
(The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The
nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate
back to the chair, and sit down. The nurse should observe the client's ability to perform
, the test and use a stopwatch to time the client. The nurse should identify that the client
is at increased risk of falls if it takes longer than 14 seconds to complete the test.)
A nurse in an orthopedic clinic is documenting data about several clients. Which of the
following actions should the nurse take to comply with the regulations of the Health
Portability and Accountability Act (HIPAA)? -Answer: Lock or log off computers
whenever he leaves the area.
(To prevent unauthorized access to clients' protected health information, all clinic staff
should lock or log off computer terminals and turn off the monitor anytime they leave
the computer unattended. This action demonstrates compliance with the HIPAA
Security Rule.)
A home health nurse is providing teaching to the parent of a child who is receiving
chemotherapy and experiencing nausea. Which of the following statements should the
nurse make? -Answer: "Have your child rest with his head elevated after meals."
(The nurse should instruct the parent to have the child rest with his head elevated after
meals. This will allow for easier digestion and help to decrease the nausea associated
with eating.)
A nurse is preparing to document care in a client's medical record. In adherence with
the Joint Commission National Patient Safety Goals regarding communication errors,
which of the following entries should the nurse make? -Answer: "Client medicated
with morphine 5 mg IM for pain."
(The nurse is using approved abbreviations and providing accurate and detailed
information, which should reduce communication errors according to the Joint
Commission National Patient Safety Goals.)
A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
clients should the nurse monitor for the development of reflex urinary incontinence? -
Answer: A client who has a T12 spinal cord injury.
(The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of
developing reflex urinary incontinence. With this type of incontinence, the client is
unaware that the bladder is full and therefore lacks the urge to void, resulting in the
involuntary loss of urine. The nurse should monitor for this form of incontinence and
implement interventions such as intermittent catheterization.)
A nurse is reviewing a client's new prescriptions that were just documented in the
client's medical record by the provider. Which of the following abbreviations should the
nurse clarify with the provider? -Answer: Enoxaparin 40 mg SQ QD
(The nurse should clarify this prescription with the provider. The abbreviations "SQ"
and "QD" are considered error-prone and should not be used in documentation. The
nurse should clarify that the provider intends the prescription to be administered
subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ"
and "daily" should be used instead of "QD.")
A community health nurse is participating in a task force initiative to reduce the
incidence of disease from injection drug use among the city's homeless population.
Assessment Level 1
A nurse in a long-term care facility discovers a small fire in a client's trash can. After
moving the client to safety, which of the following actions should the nurse take next? -
Answer: Pull the alarm to notify emergency services.
(Evidence-based practice indicates the nurse should first rescue and remove clients in
immediate danger and then activate the alarm to notify authorities of the situation.)
A nurse is preparing to leave the room who is on isolation precautions. Which of the
following actions should the nurse take when removing a tied surgical mask? -Answer:
Remove the mask by securely holding the ties and moving it away from the face.
(The nurse should untie the bottom strings and then the top strings. Finally, while still
holding the strings, the nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which is contaminated.)
A nurse is searching electronic databases for clinical research about behavioral
indicators. Which of the following online sources should the nurse select to research this
infant care issue? -Answer: Cumulative Index to Nursing and Allied Health Literature
(CINAHL)
(The nurse should select the Cumulative Index to Nursing and Allied Health Literature
(CINAHL) to locate clinical research about health-related client care issues. CINAHL is
a cumulative index that the nurse can search electronically to locate reliable data related
to the specific topic being researched.)
A nurse is preparing to administer three medications to a client who has an NG tube: a
levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -Answer: Crush the
levothyroxine tablet into a powder and dissolve it into 30 mL of warm sterile water.
(The nurse should prepare simple tablets for NG administration by crushing them into a
fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can
cause discomfort. Sterile water eliminates the possible problem of chemicals in tap
water interacting with the medication.)
A nurse is planning care who has an indwelling urinary catheter. Which of the following
interventions include in the plan to prevent the development of a catheter-associated
urinary tract infection (CAUTI)? -Answer: Secure the catheter tubing to the client's leg.
(The nurse should assess the client's need for urinary catheterization and should follow
evidence-based practice to prevent or reduce the risk of CAUTI development. This
includes securing the catheter tubing to the client's leg so that the catheter does not
move, reducing the risk of urethral trauma and introduction of bacteria into the urinary
system.)
,A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of
the following pain scales should the nurse use to access the toddler's pain level? -
Answer: FLACC scale
(The nurse should use the FLACC scale to assess pain for a 2-year-old child. The FLACC
scale assesses facial expression, leg movement, activity, cry, and consolability in
children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.)
A nurse is caring for a client who has cancer and is planning discharge to home with
hospice care. Which of the following statements by the client indicates that he is
experiencing spiritual distress? -Answer: "I wish God had not allowed this cancer to
invade my body."
(The nurse should identify that this statement indicates the client is experiencing
spiritual distress, which occurs when there is a disturbance in a client's belief system.
This client is expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer and is scheduled for
chemotherapy. The client reports experiencing chemotherapy-induced nausea and
vomiting (CINV) during her previous round of treatment. Which of the following
interventions should the nurse include in the client's plan of care? -Answer:
Administer ondansetron to the client prior to chemotherapy administration.
(The nurse should incorporate evidence-based practice interventions into the client's
plan of care to prevent and treat CINV. Evidence-based research indicates that
prevention of CINV is best achieved when antiemetics, such as ondansetron, are given
prior to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client following a brief stay in
acute care. In adherence with the Joint Commission National Patient Safety Goals
regarding medication administration, which of the following actions should the nurse
take? -Answer: Compare a list of the client's current medications with the ones he will
take in long-term care.
(The Joint Commission National Patient Safety Goals regarding medication
reconciliation includes maintaining and communicating accurate client medication
information. The nurse should complete a medication reconciliation to identify and
resolve any discrepancies by comparing the client's list of current medications with the
medications he will take in the long-term care facility and addressing any duplications,
omissions, or interactions.)
A nurse in a long-term care facility is performing a fall risk assessment on a newly
admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod
cane for ambulation. Which of the following actions should the nurse take when using
this test? -Answer: Observe the client ambulating a distance of 3 m (10 feet) during the
TUG test.
(The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The
nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate
back to the chair, and sit down. The nurse should observe the client's ability to perform
, the test and use a stopwatch to time the client. The nurse should identify that the client
is at increased risk of falls if it takes longer than 14 seconds to complete the test.)
A nurse in an orthopedic clinic is documenting data about several clients. Which of the
following actions should the nurse take to comply with the regulations of the Health
Portability and Accountability Act (HIPAA)? -Answer: Lock or log off computers
whenever he leaves the area.
(To prevent unauthorized access to clients' protected health information, all clinic staff
should lock or log off computer terminals and turn off the monitor anytime they leave
the computer unattended. This action demonstrates compliance with the HIPAA
Security Rule.)
A home health nurse is providing teaching to the parent of a child who is receiving
chemotherapy and experiencing nausea. Which of the following statements should the
nurse make? -Answer: "Have your child rest with his head elevated after meals."
(The nurse should instruct the parent to have the child rest with his head elevated after
meals. This will allow for easier digestion and help to decrease the nausea associated
with eating.)
A nurse is preparing to document care in a client's medical record. In adherence with
the Joint Commission National Patient Safety Goals regarding communication errors,
which of the following entries should the nurse make? -Answer: "Client medicated
with morphine 5 mg IM for pain."
(The nurse is using approved abbreviations and providing accurate and detailed
information, which should reduce communication errors according to the Joint
Commission National Patient Safety Goals.)
A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
clients should the nurse monitor for the development of reflex urinary incontinence? -
Answer: A client who has a T12 spinal cord injury.
(The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of
developing reflex urinary incontinence. With this type of incontinence, the client is
unaware that the bladder is full and therefore lacks the urge to void, resulting in the
involuntary loss of urine. The nurse should monitor for this form of incontinence and
implement interventions such as intermittent catheterization.)
A nurse is reviewing a client's new prescriptions that were just documented in the
client's medical record by the provider. Which of the following abbreviations should the
nurse clarify with the provider? -Answer: Enoxaparin 40 mg SQ QD
(The nurse should clarify this prescription with the provider. The abbreviations "SQ"
and "QD" are considered error-prone and should not be used in documentation. The
nurse should clarify that the provider intends the prescription to be administered
subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ"
and "daily" should be used instead of "QD.")
A community health nurse is participating in a task force initiative to reduce the
incidence of disease from injection drug use among the city's homeless population.
