ATI fundamentals practice A
High-Yield Nursing Clinical Judgment Scenarios
331. Cane Use: Identifying Correct Technique
Scenario: A nurse is evaluating a client's use of a cane.
Question: Which of the following actions should the nurse identify as an
indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.
Correct Answer: 3. The client holds the cane on the stronger side of her
body.
Rationale: Holding the cane on the stronger side provides optimal support
and helps maintain proper body alignment during ambulation.
332. IV Infusion Rate: Initial Nursing Assessment
Scenario: A nurse receives a report about a client with 0.9% sodium
chloride infusing IV at 125mL/hr. Upon initial assessment, only 80mL has
infused over the last 2 hr.
Question: Which of the following actions should the nurse take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction.
Correct Answer: 4. Check the IV tubing for obstruction.
Rationale: The priority is to identify and resolve the most likely cause of the
decreased infusion rate, which could be a simple mechanical obstruction in
the tubing.
,333. NG Tube Insertion: Facilitating Passage
Scenario: A nurse is caring for a client who requires an NG tube for
stomach decompression.
Question: Which of the following actions should the nurse take when
inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to
insertion.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion into the
esophagus.
Correct Answer: 4. Have the client take sips of water to promote insertion
of the NG tube into the esophagus.
Rationale: Swallowing helps close the epiglottis, guiding the NG tube into
the esophagus rather than the trachea.
334. Fluid and Electrolyte Balance: Identifying Reportable Findings
Scenario: A nurse is reviewing a client's fluid and electrolyte status.
Question: Which of the following findings should the nurse report to the
provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L
Correct Answer: 4. Potassium 5.4 mEq/L
Rationale: A potassium level of 5.4 mEq/L is slightly above the expected
reference range (3.5-5.0 mEq/L) and poses a risk for cardiac dysrhythmias,
requiring provider notification.
335. Walker Use: Assessing Client Understanding
Scenario: A nurse is providing discharge instructions to a client who will be
using a walker.
Question: Which of the following client statements indicates an
understanding of the teaching?
1. "I can place an extension cord across my living room to plug in my
television."
, 2. "I will hire someone to trim the tree that hangs low over the stairs of
my front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one."
Correct Answer: 2. "I will hire someone to trim the tree that hangs low
over the stairs of my front porch."
Rationale: Removing potential tripping hazards in the client's environment
is crucial for safe walker use and fall prevention.
336. Post-Stroke Care: Delegating Tasks to Assistive Personnel (AP)
Scenario: A nurse is planning care for a client who has had a stroke,
resulting in aphasia and dysphagia.
Question: Which of the following tasks should the nurse assign to an
assistive personnel? (Select all that apply)
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an
antihypertensive medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter.
Correct Answers: 1, 2, 4
Rationale: Assisting with basic hygiene (bed bath), measuring stable vital
signs (BP after medication), and facilitating communication using
established tools (communication board) are within the typical scope of
practice for an AP and pose low risk to the client. Swallowing assessment
and catheter irrigation require nursing judgment and skill.
337. Client Anger: Therapeutic Nursing Response
Scenario: A nurse is caring for a client who is expressing anger about his
diagnosis of colorectal cancer.
Question: Which of the following actions should the nurse take?
1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to
manage his illness.
3. Provide the client with written information about the phases of loss
and grief.
4. Reassure the client that this is an expected response to grief.
High-Yield Nursing Clinical Judgment Scenarios
331. Cane Use: Identifying Correct Technique
Scenario: A nurse is evaluating a client's use of a cane.
Question: Which of the following actions should the nurse identify as an
indication of correct use?
1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.
Correct Answer: 3. The client holds the cane on the stronger side of her
body.
Rationale: Holding the cane on the stronger side provides optimal support
and helps maintain proper body alignment during ambulation.
332. IV Infusion Rate: Initial Nursing Assessment
Scenario: A nurse receives a report about a client with 0.9% sodium
chloride infusing IV at 125mL/hr. Upon initial assessment, only 80mL has
infused over the last 2 hr.
Question: Which of the following actions should the nurse take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction.
Correct Answer: 4. Check the IV tubing for obstruction.
Rationale: The priority is to identify and resolve the most likely cause of the
decreased infusion rate, which could be a simple mechanical obstruction in
the tubing.
,333. NG Tube Insertion: Facilitating Passage
Scenario: A nurse is caring for a client who requires an NG tube for
stomach decompression.
Question: Which of the following actions should the nurse take when
inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to
insertion.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion into the
esophagus.
Correct Answer: 4. Have the client take sips of water to promote insertion
of the NG tube into the esophagus.
Rationale: Swallowing helps close the epiglottis, guiding the NG tube into
the esophagus rather than the trachea.
334. Fluid and Electrolyte Balance: Identifying Reportable Findings
Scenario: A nurse is reviewing a client's fluid and electrolyte status.
Question: Which of the following findings should the nurse report to the
provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L
Correct Answer: 4. Potassium 5.4 mEq/L
Rationale: A potassium level of 5.4 mEq/L is slightly above the expected
reference range (3.5-5.0 mEq/L) and poses a risk for cardiac dysrhythmias,
requiring provider notification.
335. Walker Use: Assessing Client Understanding
Scenario: A nurse is providing discharge instructions to a client who will be
using a walker.
Question: Which of the following client statements indicates an
understanding of the teaching?
1. "I can place an extension cord across my living room to plug in my
television."
, 2. "I will hire someone to trim the tree that hangs low over the stairs of
my front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one."
Correct Answer: 2. "I will hire someone to trim the tree that hangs low
over the stairs of my front porch."
Rationale: Removing potential tripping hazards in the client's environment
is crucial for safe walker use and fall prevention.
336. Post-Stroke Care: Delegating Tasks to Assistive Personnel (AP)
Scenario: A nurse is planning care for a client who has had a stroke,
resulting in aphasia and dysphagia.
Question: Which of the following tasks should the nurse assign to an
assistive personnel? (Select all that apply)
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an
antihypertensive medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter.
Correct Answers: 1, 2, 4
Rationale: Assisting with basic hygiene (bed bath), measuring stable vital
signs (BP after medication), and facilitating communication using
established tools (communication board) are within the typical scope of
practice for an AP and pose low risk to the client. Swallowing assessment
and catheter irrigation require nursing judgment and skill.
337. Client Anger: Therapeutic Nursing Response
Scenario: A nurse is caring for a client who is expressing anger about his
diagnosis of colorectal cancer.
Question: Which of the following actions should the nurse take?
1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to
manage his illness.
3. Provide the client with written information about the phases of loss
and grief.
4. Reassure the client that this is an expected response to grief.
