ATI CBC Level 1 Practice A Exam with Rationales 2025

1. Nurse assessing preschooler with UTI, which of the following findings should the nurse expect? - Abdominal Pain Rationale: also included constipation, dysuria, foul-smelling urine, and fever 2. Nurse is counseling a client who has a family history of colorectal cancer about nutrition management to help prevent GI cancers. Which image indicates what the nurse should encourage the client to include liberally in diet? - Fruit Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day per female, consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat), NOT white bread (refined grain products) 3. A nurse is preparing to extinguish a small fire in clients room. Which of the following actions should the nurse take when using the fire extinguisher? - Slide the pin on top of the fire extinguisher straight out Rationale: This allows use of the extinguisher, should aim at base of the fire, squeeze the handles, sweep from side to side to expel it evenly (not circular) 4. A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's meal tray? - Oatmeal with raisins Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can give scrambled eggs, corn (corn flake cereal), and orange juice. This disease can cause diarrhea, weight loss, abd pain, and fatigue when consuming gluten. 5. A nurse at a providers office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into a sleep promotion plan? - "Sleep in the location of your home where you feel you rest best" Rationale: encourage client to sleep where they sleep best (couch, bed, chair), DO NOT consume alcohol in late afternoon or evening (it can inhibit sleep, if needed consume earlier in the day. DO NOT turn on TV, light and noise at bedtime can reduce sleep, also Maintain regular sleep and wake times to improve sleep patterns 6. A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks the preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect? - "It's wrong because my dad said I can't kick her" Rationale: The nurse should expect the preschooler to be motivated to choose right from wrong because of the rules taught to him by his parents. He will not yet choose right from wrong bc of how his actions affect others (more focused on how will affect himself) 7. 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 med admin, which of the following actions should the nurse take? - Compare a list of the clients current medications with the ones he will take in long-term care. Rationale: this includes maintaining and communicating Accurate client medication information. 8. A nurse is caring for a client who is 2 days post op following an above-theknee 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 clients pain? - Administer a beta-blocking medication to the client Rationale: These have been shown to relieve the phantom limb pain manifestations of dull and burning type pain. The nurse should position client on a firm mattress to prevent hip flexor contractures. Might be able to use heat, ultrasound therapy, or transcutaneous electrical nerve stimulation for PLP. Bandage should be secured snugly to reduce edema and promote limb shrinkage. Loosening it will not help PLP. 9. A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? - "I can give her watermelon pieces after I remove the seeds" Rationale: can easily choke on seeds or pits. Can easily choke on grapes (peeling them don't help), have to cut grapes into small pieces before offering them to a toddler, can easily choke on popcorn bc of its tendency to swell and not dissolve (not putting salt or butter helps nutritionally but not for choking), can easily choke on hot dog slices (slicing thinly doesn't help) 10. A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue? - Cumulative Index to Nursing and Allied Health Literature (CINAHL) Rationale: use to locate clinical research about health-related client care issues. 11. A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? - Delay the clients meal time if he is fatigued Rationale: To promote safety, the nurse should encourage the client to rest prior to meal time. If fatigued, give client time to rest. Should instruct to tilt head forward, avoid using a syringe to force fluids into their mouth, nurse should attempt to eliminate distractions and disruptions while PT is eating (TV) 12. 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? - Observe the client ambulating a distance of 3 m (10 feet) during the TUG test Rationale: instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. Observe clients ability and use stopwatch. If longer than 14 seconds then at increased risk for falls. Use assistive aid if have one. Nurse avoid assisting them to stand. Client should avoid using the arms of the chair for assistance when standing. 13. A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16 year old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent? - Witness consent obtained from the infants mother. Rationale: The nurse should assist in obtaining informed consent from the mother by witnessing her signature. A minor even if unemancipated can provide consent for her infant. They can also legally provide informed consent for STI tx, substance use tx, and care related to pregnancy in some states. Use the grandparent if legal guardian or if parent is unavailable. Use court if parent is not acting in child's best interest. 14. 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? - Perform hand hygiene before touching the IV tubing. Rationale: hand hygiene before touching any part of the infusion system or the client to reduce the risk of infection. Change bags of IV solution every 24 hr, use antimicrobial agents (alcohol, povidone-iodine, or chlorhexidine) NOT hydrogen peroxide for sure care, check IV site every 4 hr for manifestations of infection at the insertion site 15. A nurse is caring for an adolescent client who is in critical condition following a MVA in which he was the passenger. The clients 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? - Inform the parent that anger is a natural response when dealing with loss. Rationale: Nurse should identify that the parent is in the anger stage of grief. Parent should talk to nurse or grief counselor. Encourage parent to remain in the facility to talk about her feelings and offer a safe environment. Offer clergy member, don't get clergy without asking first. 16. A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make? - "Your advance directives can designate a friend to make your health care decisions" Rationale: The client can choose anyone to make health care decisions for him if he's unable to. Nurse make sure that this form is witnessed or notarized according the state law. These are written documents with 1 or 2 witnesses. Next of kin can't change the info on the document even if PT is unconscious. 17. A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching? - "I should use a warm paraffin dip for my hands and feet" Rationale: Instruct PT to maintain healthy weight (limiting purine is for gout not RA bc it breaks down into Uric acid), take warm shower in morning to help with stiffness and mobility, continue participating in physical activities as tolerated. 18. A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? - "Wash your child exposed clothing with hot water and detergent" Rationale: flush exposed skin with water within 15 minutes of exposure, don't scrub it or use antibacterial soap (this will allow it to spread bc it removes protective skin oils and dilutes the urushiol), touching other kids with it won't spread it (have to touch the plant) 19. A nurse is preparing to administer intermittent enteral nutrition via a clients NG tube. In which order should the nurse take the following actions? - 1. Assist into high Fowler's (sit them up) 2. Verify tube placement by aspirating 5 mL of gastric contents 3. Test the aspirate pH 4. Check for gastric residual volume (GRV) (Excessive GRV shows delayed gastric emptying -at risk for aspiration if more given) 5. Flush the tubing with 30 mL of water (to ensure the tube is clear and patent) 20. A nurse is providing change of shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? - "The client has been very tearful since finding out he has diabetes mellitus" Rationale: nurse should include significant info such as a new dx. Should also identify changes in the clients emotional status that might indicate a need for additional client support and teaching. Include PRN meds (med,dose,route, and time), include vitals if they have significantly changed or interventions were required, don't include visitors unless there was a problem 21. A nurse is planning care for a newly admitted school age child who has rubeola. Which isolation precautions should the nurse plan to initiate? - Airborne Rationale: airborne for varicella, measles (rubeola), or pulmonary TB. Private room with negative pressure airflow with 6-12 air exchanges/hr via a HEPA filtration system. Droplet (rubella, strep pharyngitis, pertussis and meningococcal pneumonia). Contact (c diff, scabies, shigella, herpes). Protective environment (severely immunocompromised PT) 22. A nurse is preparing to leave the room of a client who is on isolation precautions. Which action should the nurse take when removing a tied surgical mask? - Remove the mask by securely holding the ties and moving it away from the face. Rationale: untie bottom strings then top strings to prevent mask falling forward onto nurse chest, hand hygiene after removing and discarding mask, remove the tied mask at the doorway of the clients room (if respirator mask, then remove after leaving clients room and closing the door) 23. A nurse is caring for a client who has cancer and is planning to discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? - " I wish God had not allowed this cancer to invade my body" Rationale: Spiritual distress occurs when there is a disturbance in a clients belief system. This client is expressing spiritual anger and not accepting his condition. 24. A nurse is teaching a young adult female client about health screening for breast cancer. Which statement by the client indicates an understanding of breast self examination (BSE)? - " I should expect to feel a firm ridge along the bottom curve of each breast" Rationale: Performing a BSE promotes breast self awareness so that the client knows how her breasts normally feel. This helps the client identify changes that require further evaluation and treatment. Perform it 1 week after her period each month. Lie down, palpate right breast with left hand finger pads. Raise right arm. Then switch and do the opposite. 25. A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plan to take? - Gradually lengthen the time between the clients scheduled voids Rationale: bladder retraining is the main goal. The client is encouraged and taught to suppress the urge to void between scheduled voids through the use of pelvic exercises, distraction, and abdominal breathing. Do not apply an adult diaper, and do not assist the client to the toilet as soon as the urge to avoid is reported. Instead, Use distraction and deep breathing until the urge passes once the urge passes you can assist the client to the toilet. Decrease fluid intake after 1800. 26. A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. Which of the following actions should the nurse take? - Have the client lay supine Rationale: this is a comfortable position for the client, and it makes it easy for the nurse to access the eye. It also reduces the risk of the medication escaping through the tear duct. The client should look up not down. The nurse should place a finger on the clients cheek bone not the eyelid to draw the skin downward this helps avoid touching the cornea, causing blinking, and avoids pressure on the eye. The nurse should put the medication into the outer third of the lower conjunctival sac. 27. A nurse in a long-term care facility discovers a small fire in a clients trashcan. After moving the client to safety, which of the following actions should the nurse take next? - Pull the alarm to notify emergency services Rationale: you always rescue and remove clients in immediate danger and then activate the alarm. After the alarm you will turn off oxygen and electrical equipment, close the doors and windows on the unit, and attempt to extinguish the fire 28. A nurse on a pediatric unit is admitting an infant who has pertussis. Which of the following isolation precautions should the nurse initiate? - Droplet Rationale: this also includes rubella, streptococcal pharyngitis, and diphtheria. This includes a private room and a mask or respirator. Airborne precautions would be used for measles, Varicella, and tuberculosis. Contact precautions would be used for scabies, herpes, respiratory Syncytial virus and shigella. 29. A Community Health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the cities homeless population. Which of the following plants to the nurse recommend as part of tertiary prevention? - Start a needle exchange program Rationale: initiating a program for needle exchange and treating clients who are homeless for any diseases they may already have acquired are examples of tertiary prevention. Primary prevention would include providing community education about needle sharing. Secondary prevention would be HIV testing/testing for diseases that have an association with injection drug use and screening clients who are homeless for drug use 30. A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following findings should the nurse identify as a need for administration of a PRN pain medication? - Rapid breathing Rationale: shallow rapid breathing is a nonverbal indicator of acute pain. Other nonverbal indicators of pain include muscle tension, restlessness, moaning, Hyper active reflexes, and dilated pupils. 31. A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the joint commission national patient safety goals regarding blood administration, which of the following actions should the nurse plan to take? - Verify the client and blood component using a two person process Rationale: this will help eliminate transfusion errors. The nurse should also review the clients medical record for previous transfusion information, administer pre-medication to the client as prescribed by the provider such as diphenhydramine and acetaminophen, and should educate the client about manifestations such as dyspnea or back pain and to report them to the nurse immediately. But, the answer adheres to the national patient safety goals regarding transfusions. 32. 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? - Offer the client a glass of water every two hours when repositioning. Rationale: this helps prevent dehydration. Avoid massaging the clients skin and pressure points, applying corn starch or baby powder because it can create gritty debris that can abrade the skin, and avoid donut and sheepskin devices (can further dec mobility) 33. A nurse is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make? - " take NSAIDs for body aches and pain." Rationale: alternative therapies include tai chi, herbal supplements and massage. Sore throat and other flu like manifestations are expected with chronic fatigue syndrome. Encourage adequate sleep, proper nutrition, and regular exercise. Excessive exercise can increase fatigue. 34. A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. Which of the following actions should the nurse take? - Pull up a small amount of skin using the thumb and forefinger of the non-dominant hand Rationale: this helps reduce the pain of the injection. It should be given at a 45° or 90° angle. Use a needle that is either 1/2 or 5/8 inch long and inject the entire length of the needle. Don't aspirate. 35. A nurse is preparing to administer an immunization via IM injection into an adult clients deltoid muscle. Which of the following actions should the nurse take? - Select a 1 inch needle for the injection Rationale: depending on the clients weight the nurse might need to use a 1 1/2 inch needle to ensure injection of the vaccine into the muscle. Limit the volume to 0.5 to 1 mL when in the deltoid. Up to 3 mL when given in larger muscle (gluteals). CDC guidelines say to not aspirate with immunizations. Spread the skin when giving. 36. 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? - "The state board of nursing can provide this information" Rationale: each state develops a nurse practice act which defines scope of practice for nurses in that state. 37. A nurse is providing dietary teaching to a client who has diarrhea. Which of the following instructions should the nurse include? - Increase your intake of potassium rich foods while you are experiencing diarrhea Rationale: this includes tomatoes and potatoes. The increased intake of potassium helps reduce the risk of electrolyte imbalance due to fluid loss. Should also instruct client to increase intake of soluble fiber (oatmeal and rice) and dec insoluble fiber. Increase sodium intake to dec risk of dehydration from fluid loss. Decrease caffeine. 38. A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the clients pain? - "Can you describe what your pain feels like?" Rationale: describing the pain is used for assessing pain quality. This can be described as "piercing", "stabbing", and "aching". To assess the pattern of the pain the nurse should ask how long the episodes last. To assess for manifestations an example would be if they have any nausea when they're in pain. To assess the severity of the pain the nurse should ask them to rate their pain (1-10). 39. A charge nurse is educating unit staff about the cultural aspects of client care following death. Which of the following statements by an assistive personnel indicates an understanding of the teaching? - The body of a client who practices Islam is washed and wrapped in a cloth following death Rationale: the body of a client who practices Islam is washed wrapped prayed over and buried as soon as possible following death and the clients head should be turned toward Mecca. With Judaism a family member will stay with the body until the time of burial and they won't be buried on the Sabbath. If Chinese the oldest son or daughter will bathe the body following death and members of the clients extended family will stay with the body for eight hours following death. If Buddhism then male members of the family will prepare the body and the body will not be left alone and is usually cremated 40. A nurse manager is developing a facility policy about the use of A fax machine to communicate information from a clients electronic medical record (EMR). Which of the following actions should the nurse include in the policy? - Use a cover sheet when sending a fax from the health care unit Rationale: This protects the clients private health info. And allows the receiver to identify the intended recipient w/o reading the actual document. The nurse manager should also recommend the use of speed dial keys on the fax machine so you can program in frequently used provider numbers which reduces the risk of misdialed numbers. Only fax the requested info NOT the entire EMR. Immediately shred all copies of the EMR don't wait.