ATI NCLEX Fundamentals Assessment 1
A charge nurse in the CCU is reviewing prescriptions for a group of clients. The nurse should
identify that which of the following procedures are outside the nurse's scope of practice
A. Drawing blood from an arterial line
B. Determining a Glasgow Coma Scale score
C. Administering an antibiotic intrathecally
D. Providing initial education for a client who has type 1 diabetes - ANS-C
Intrathecal injections involve injecting medication directly into the intrathecal space of the spinal
cord. A nurse's scope of practice allows injections that are intradermal, subcutaneous,
intramuscular, and intravenous
A charge nurse is observing another nurse perform a sterile dressing change on a client. Which
of the following actions should the charge nurse identify as a contaminant to the sterile field
A. Placing a surgical mask on a client who is coughing
B. Placing sterile supplies within a 1cm (0.4in) border of the sterile field
C. Using sterile forceps to move the items on the sterile field
D. Positioning the sterile tray on the beside table 1cm (0.4in) above waist level - ANS-B
The nurse should place objects toward the center of the sterile field and away from the 2.5cm (1
in) border around the drap
A client is reviewing data for a group of clients at the beginning of the shift. For which of the
following clients should the nurse initiate a dietary referral?
A. A client whose BMI is 23
B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids
C. A client whose pre-albumin level is 11 mg/dL
D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic - ANS-C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of
acute nutritional changes!
--
A, expected range of BMI is 18.5-24.9
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for
fluid overload. However, this does not indicate a need for dietary referral.
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low
sodium levels.
A home health nurse is teaching the caregiver of a client who had a recent stroke about proper
body mechanics when repositioning the client in bed. Which of the following instructions should
the nurse include in the teaching? (Select all that apply)
, A. Elevate the bed to the height of your waist
B. Elevate the head of the bed before you move the client up in bed
C. Stand with your feet wide apart
D. Face toward the direction of movement
E. Keep your knees bent - ANS-A, C, D ,E
--
The patient should be flat to reduce the risk for injury for the caregiver
A nurse enters a client's room and sees the client on the floor next to the bed. Which of the
following actions should the nurse take first?
A. Assist the client back into bed
B. Notify the risk manager
C. Obtain the client's vital signs
D. Complete an incident report about the client's fall - ANS-C
A nurse in an acute care facility is caring for a client who has confusion and continually pulls at
her medical tubes and devices. Which of the following actions should the nurse take first
A. Obtain a written prescription to apply wrist restraints to the client
B. Apply a stockinette dressing to conceal the client's IV
C. Administer the lowest possible dose of an IV sedative to the client
D. Telephone family members to advise them that the client might require restraints - ANS-B
Use least restrictive intervention first!
A nurse in an assisted living facility observes that an older adult client who was previously
socially interactive appears withdrawn and avoids the other residents. Which of the following
actions should the nurse take first
A. Assess the client for a loss of hearing
B. Arrange transportation for the client to an outside senior activity program
C. Encourage visits from family members and friends
D. Plan a recreational activity for the client with a small group of residents - ANS-A
A nurse in the PACU is caring for a client following abdominal surgery. Which of the following
actions should the nurse take first
A. Monitor the client's oxygen saturation level
B. Assess the client's pain level
C. Reinforce the client's surgical dressing
D. Check the client's urinary output - ANS-A
The greatest risk to the client is injury from an obstructed airway
A nurse is administering a tuberculin test by the intradermal route to a client. Which of the
following steps should the nurse take?
A. Pinch the client's skin to elevate the tissue slightly before piercing the skin with the needle
B. Hold the bevel of the needle pointing downward when piercing the skin
A charge nurse in the CCU is reviewing prescriptions for a group of clients. The nurse should
identify that which of the following procedures are outside the nurse's scope of practice
A. Drawing blood from an arterial line
B. Determining a Glasgow Coma Scale score
C. Administering an antibiotic intrathecally
D. Providing initial education for a client who has type 1 diabetes - ANS-C
Intrathecal injections involve injecting medication directly into the intrathecal space of the spinal
cord. A nurse's scope of practice allows injections that are intradermal, subcutaneous,
intramuscular, and intravenous
A charge nurse is observing another nurse perform a sterile dressing change on a client. Which
of the following actions should the charge nurse identify as a contaminant to the sterile field
A. Placing a surgical mask on a client who is coughing
B. Placing sterile supplies within a 1cm (0.4in) border of the sterile field
C. Using sterile forceps to move the items on the sterile field
D. Positioning the sterile tray on the beside table 1cm (0.4in) above waist level - ANS-B
The nurse should place objects toward the center of the sterile field and away from the 2.5cm (1
in) border around the drap
A client is reviewing data for a group of clients at the beginning of the shift. For which of the
following clients should the nurse initiate a dietary referral?
A. A client whose BMI is 23
B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids
C. A client whose pre-albumin level is 11 mg/dL
D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic - ANS-C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of
acute nutritional changes!
--
A, expected range of BMI is 18.5-24.9
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for
fluid overload. However, this does not indicate a need for dietary referral.
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low
sodium levels.
A home health nurse is teaching the caregiver of a client who had a recent stroke about proper
body mechanics when repositioning the client in bed. Which of the following instructions should
the nurse include in the teaching? (Select all that apply)
, A. Elevate the bed to the height of your waist
B. Elevate the head of the bed before you move the client up in bed
C. Stand with your feet wide apart
D. Face toward the direction of movement
E. Keep your knees bent - ANS-A, C, D ,E
--
The patient should be flat to reduce the risk for injury for the caregiver
A nurse enters a client's room and sees the client on the floor next to the bed. Which of the
following actions should the nurse take first?
A. Assist the client back into bed
B. Notify the risk manager
C. Obtain the client's vital signs
D. Complete an incident report about the client's fall - ANS-C
A nurse in an acute care facility is caring for a client who has confusion and continually pulls at
her medical tubes and devices. Which of the following actions should the nurse take first
A. Obtain a written prescription to apply wrist restraints to the client
B. Apply a stockinette dressing to conceal the client's IV
C. Administer the lowest possible dose of an IV sedative to the client
D. Telephone family members to advise them that the client might require restraints - ANS-B
Use least restrictive intervention first!
A nurse in an assisted living facility observes that an older adult client who was previously
socially interactive appears withdrawn and avoids the other residents. Which of the following
actions should the nurse take first
A. Assess the client for a loss of hearing
B. Arrange transportation for the client to an outside senior activity program
C. Encourage visits from family members and friends
D. Plan a recreational activity for the client with a small group of residents - ANS-A
A nurse in the PACU is caring for a client following abdominal surgery. Which of the following
actions should the nurse take first
A. Monitor the client's oxygen saturation level
B. Assess the client's pain level
C. Reinforce the client's surgical dressing
D. Check the client's urinary output - ANS-A
The greatest risk to the client is injury from an obstructed airway
A nurse is administering a tuberculin test by the intradermal route to a client. Which of the
following steps should the nurse take?
A. Pinch the client's skin to elevate the tissue slightly before piercing the skin with the needle
B. Hold the bevel of the needle pointing downward when piercing the skin
