ATI Fundamentals Proctored Exam
A long-term care facility charge nurse is preparing a training program for newly hired nurses on
delirium. Which of the following statements ought to be included in the nurse's plan? A.
Delirium has an abrupt onset - ANS-a
A long-term care facility charge nurse is preparing a training program for newly hired nurses on
delirium. Which of the following statements ought to be included in the nurse's plan? a.
"Delirium does not affect a client's perception of her environment."
b. "A client's sleep cycle is unaffected by delirium." c. "Delirium begins suddenly." d. ANS-c:
"Delirium progresses slowly." A group of newly licensed nurses is being taught how to use
restraints by a charge nurse. In which of the following clinical situations should the nurse apply
restraints?
a. If the client is pacing in the hallway
b. as part of a program to prevent falls c. At the request of the client's family
d. When the client poses a threat to self - ANS-d
A community health nurse is teaching a group of clients about kegel exercises to prevent
urinary incontinence. Which of the following instructions should the nurse include?
A. Contact your pelvic muscle when performing the exercises
B.Expect improvement after 2 weeks of performing the exercises C. Hold your breath when
performing the exercises
D. When doing the exercises, tighten your buttocks - ANS-a. A home care nurse is teaching a
client about home safety. Which of the following client statements indicates comprehension of
the instruction? (pick all relevant options) a. When I enter and exit the bathtub, I will use the
bars. b. I need to check my medications for expiration dates
c. I need to have a fire escape plan with my family
d. I will apply tape over frayed areas of electrical cords
e. My hot water heater must be set to 140 degrees Fahrenheit - ANS-a, b, and c. A client is
receiving instruction on home safety from a home health nurse. Which of the following client
statements indicates comprehension of the instruction? (SATA)
- I need to check the expiration dates on my medications. - When entering and exiting the
bathtub, I will use the grab bars. - My family and I must have a fire escape strategy: ANS-a, b,
and c A client with terminal cancer is receiving care from a hospice nurse. Which of the following
interventions should the nurse include to promote the client's dignity?
a. Offer the client guided imagery exercises. b. Refrain from discussing the client's prognosis
c. Suggest that the client keep a journal.
d. The client should be encouraged to tell their life story. - ANS-b A client with a seizure
disorder is greeted by a nurse as she enters the room. The client is sitting in a chair and begins
to experience a seizure. The nurse should proceed with which of the following actions first. a.
Move items in the room away from the client
b. Get the client on your side. c. Help the client lie on the floor
d. Loosen the client's clothing - ANS-c
, A client is being evaluated by a nurse in a long-term care facility. The nurse should consider
which of the following findings to be an indication of a fecal impaction. a. Seepage of liquid
stool - ANS-a
In a long-term care facility, a nurse is planning the care of four patients. Which of the following
client's is at greatest risk of developing a pressure ulcer?
a. A client who is incontinent of urine 1 to 2 times a day
b. A patient who is fed through an enteral tube c. Client who requires assistance to transfer
from the bed to a chair d. Client who is unresponsive to pain stimuli - ANS-d
Preparing to move a patient to a long-term facility is a nurse in an acute care facility. Which one
of Should the nurse include the following information in the hand-off report? a. Effectiveness of
the last dose of pain medication - ANS-a
a nurse in an emergency department is assessing a client who reports a right lower quadrant
pain, nausea and vomiting for the past 48 hours? The nurse should proceed with which of the
following actions first. a. Offer pain medication
b. Palpate the abdomen c.Auscultate bowel sounds
d.Administer an antiemetic - ANS-c
A nurse is admitting a client who has a clostridium difficile infection. The nurse ought to take
which of the following actions? Pick all options that apply. a. Use an N95 respirator while
providing client care
b. when serving customers, don a gown and gloves. c. assign the client to a private room with
positive air flow
d. wash hands with soap and water after contact with the client
e. Ensure the client does not receive fresh fruits - ANS-b, c, d
A client with malnutrition is admitted by a nurse. The client states, "My wedding ring is loose
and I'm worried I will lose it if it falls off." Which of the following is an appropriate response by
the nurse?
a. " I will place it in your drawer so it won't get lost."
b. I can pin it to your hospital gown so you won't lose it."
c. "I will keep it until a member of my family can bring it home." d. I can secure it for you in a
storage unit - ANS-d. A nurse is assessing a client who has diabetes mellitus prior to performing
a blood glucose test. Which of the following findings should indicate to the nurse that the client
has hyperglycemia?
A. Thirst
B. Confusion
C. Coolskin
D. Shakiness - ANS-a
A nurse is assessing a client who is immobile and notices a red area over the client's coccyx.
The nurse ought to take which of the following actions? a. Change the clients position every 4
hours
b. Apply petroleum base ointment in the red area
c. Assess the red area for blanching
d. Use friction when cleansing the client's skin - ANS-c
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the
following finding is the nurse's priority?
, a. Three days ago, I had my last bowel movement. b. Reports pain of 8 on a scale of 0 to 10
c. Distended bladder
d. Respiratory rate 7/min - ANS-d
A client's personal hygiene is being evaluated by a nurse. Which of the following findings
indicates that the client might have difficulty with routinely bruising their teeth?
A. Theclientsmucosaismoist
B. The client's gums appear pliable. C. The client has a tooth that is missing. D. The Client's
tongue is a dull red color - ANS-b
A nurse is assessing an older adult client. Which of the following findings should the nurse
expect?
a. Decreased sense of balance - ANS-a
A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
a. Slide the probe across the clients forehead
b. Pull the clients pinna up & back
c. Hold the client's hair aside while performing the procedure
d. Document the client's temperature with "AX" next to the value
e. Move the probe in a circular motion - ANS-a, c
A client's skin is being examined by a nurse, who has been working outside for 20 years. The
nurse's priority is which of the following findings. A. Skin tags noted in the neck region
B. A change in appearance of a mole on the shoulder
C. A flat, nonpalpable, discovered area of skin on the trunk
D. Atrophic wart on the left index finger - ANS-b
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast.
Which of the following actions should the nurse use?
A. Encourage the client to try to defecate for 20 min while on the fracture pan.
B. Keep the bed flat while the client is on the fracture pan.
C. Hyperextend the clients back while the fracture pan is in place.
D. Place the shallow end of the fracture pan under the clients buttocks. - ANS-d
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and
avoids looking at her dressings. The nurse should proceed with which of the following actions
first. A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to
a breast cancer support group
C. determine how the client's mastectomy affected their body image. D. Persuade the client to
help her change her clothes - ANS-c A nurse is caring for a client following a laparoscopic
cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for
nausea and vomiting. Determine the order in which the nurse should administer the medication.
( Move the steps into the box on the right, placing them in the order of performance. Use all the
steps.)
- Select the injection port of the IV tubing closest to the client.
- Use an antiseptic swab to clean the injection port. - Aspirate for blood return.
- Inject the medication.
- perform hand hygiene - ANS-1. perform hand hygiene
2. select the injection port of the IV tubing closest to the client
A long-term care facility charge nurse is preparing a training program for newly hired nurses on
delirium. Which of the following statements ought to be included in the nurse's plan? A.
Delirium has an abrupt onset - ANS-a
A long-term care facility charge nurse is preparing a training program for newly hired nurses on
delirium. Which of the following statements ought to be included in the nurse's plan? a.
"Delirium does not affect a client's perception of her environment."
b. "A client's sleep cycle is unaffected by delirium." c. "Delirium begins suddenly." d. ANS-c:
"Delirium progresses slowly." A group of newly licensed nurses is being taught how to use
restraints by a charge nurse. In which of the following clinical situations should the nurse apply
restraints?
a. If the client is pacing in the hallway
b. as part of a program to prevent falls c. At the request of the client's family
d. When the client poses a threat to self - ANS-d
A community health nurse is teaching a group of clients about kegel exercises to prevent
urinary incontinence. Which of the following instructions should the nurse include?
A. Contact your pelvic muscle when performing the exercises
B.Expect improvement after 2 weeks of performing the exercises C. Hold your breath when
performing the exercises
D. When doing the exercises, tighten your buttocks - ANS-a. A home care nurse is teaching a
client about home safety. Which of the following client statements indicates comprehension of
the instruction? (pick all relevant options) a. When I enter and exit the bathtub, I will use the
bars. b. I need to check my medications for expiration dates
c. I need to have a fire escape plan with my family
d. I will apply tape over frayed areas of electrical cords
e. My hot water heater must be set to 140 degrees Fahrenheit - ANS-a, b, and c. A client is
receiving instruction on home safety from a home health nurse. Which of the following client
statements indicates comprehension of the instruction? (SATA)
- I need to check the expiration dates on my medications. - When entering and exiting the
bathtub, I will use the grab bars. - My family and I must have a fire escape strategy: ANS-a, b,
and c A client with terminal cancer is receiving care from a hospice nurse. Which of the following
interventions should the nurse include to promote the client's dignity?
a. Offer the client guided imagery exercises. b. Refrain from discussing the client's prognosis
c. Suggest that the client keep a journal.
d. The client should be encouraged to tell their life story. - ANS-b A client with a seizure
disorder is greeted by a nurse as she enters the room. The client is sitting in a chair and begins
to experience a seizure. The nurse should proceed with which of the following actions first. a.
Move items in the room away from the client
b. Get the client on your side. c. Help the client lie on the floor
d. Loosen the client's clothing - ANS-c
, A client is being evaluated by a nurse in a long-term care facility. The nurse should consider
which of the following findings to be an indication of a fecal impaction. a. Seepage of liquid
stool - ANS-a
In a long-term care facility, a nurse is planning the care of four patients. Which of the following
client's is at greatest risk of developing a pressure ulcer?
a. A client who is incontinent of urine 1 to 2 times a day
b. A patient who is fed through an enteral tube c. Client who requires assistance to transfer
from the bed to a chair d. Client who is unresponsive to pain stimuli - ANS-d
Preparing to move a patient to a long-term facility is a nurse in an acute care facility. Which one
of Should the nurse include the following information in the hand-off report? a. Effectiveness of
the last dose of pain medication - ANS-a
a nurse in an emergency department is assessing a client who reports a right lower quadrant
pain, nausea and vomiting for the past 48 hours? The nurse should proceed with which of the
following actions first. a. Offer pain medication
b. Palpate the abdomen c.Auscultate bowel sounds
d.Administer an antiemetic - ANS-c
A nurse is admitting a client who has a clostridium difficile infection. The nurse ought to take
which of the following actions? Pick all options that apply. a. Use an N95 respirator while
providing client care
b. when serving customers, don a gown and gloves. c. assign the client to a private room with
positive air flow
d. wash hands with soap and water after contact with the client
e. Ensure the client does not receive fresh fruits - ANS-b, c, d
A client with malnutrition is admitted by a nurse. The client states, "My wedding ring is loose
and I'm worried I will lose it if it falls off." Which of the following is an appropriate response by
the nurse?
a. " I will place it in your drawer so it won't get lost."
b. I can pin it to your hospital gown so you won't lose it."
c. "I will keep it until a member of my family can bring it home." d. I can secure it for you in a
storage unit - ANS-d. A nurse is assessing a client who has diabetes mellitus prior to performing
a blood glucose test. Which of the following findings should indicate to the nurse that the client
has hyperglycemia?
A. Thirst
B. Confusion
C. Coolskin
D. Shakiness - ANS-a
A nurse is assessing a client who is immobile and notices a red area over the client's coccyx.
The nurse ought to take which of the following actions? a. Change the clients position every 4
hours
b. Apply petroleum base ointment in the red area
c. Assess the red area for blanching
d. Use friction when cleansing the client's skin - ANS-c
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the
following finding is the nurse's priority?
, a. Three days ago, I had my last bowel movement. b. Reports pain of 8 on a scale of 0 to 10
c. Distended bladder
d. Respiratory rate 7/min - ANS-d
A client's personal hygiene is being evaluated by a nurse. Which of the following findings
indicates that the client might have difficulty with routinely bruising their teeth?
A. Theclientsmucosaismoist
B. The client's gums appear pliable. C. The client has a tooth that is missing. D. The Client's
tongue is a dull red color - ANS-b
A nurse is assessing an older adult client. Which of the following findings should the nurse
expect?
a. Decreased sense of balance - ANS-a
A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
a. Slide the probe across the clients forehead
b. Pull the clients pinna up & back
c. Hold the client's hair aside while performing the procedure
d. Document the client's temperature with "AX" next to the value
e. Move the probe in a circular motion - ANS-a, c
A client's skin is being examined by a nurse, who has been working outside for 20 years. The
nurse's priority is which of the following findings. A. Skin tags noted in the neck region
B. A change in appearance of a mole on the shoulder
C. A flat, nonpalpable, discovered area of skin on the trunk
D. Atrophic wart on the left index finger - ANS-b
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast.
Which of the following actions should the nurse use?
A. Encourage the client to try to defecate for 20 min while on the fracture pan.
B. Keep the bed flat while the client is on the fracture pan.
C. Hyperextend the clients back while the fracture pan is in place.
D. Place the shallow end of the fracture pan under the clients buttocks. - ANS-d
A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and
avoids looking at her dressings. The nurse should proceed with which of the following actions
first. A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to
a breast cancer support group
C. determine how the client's mastectomy affected their body image. D. Persuade the client to
help her change her clothes - ANS-c A nurse is caring for a client following a laparoscopic
cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for
nausea and vomiting. Determine the order in which the nurse should administer the medication.
( Move the steps into the box on the right, placing them in the order of performance. Use all the
steps.)
- Select the injection port of the IV tubing closest to the client.
- Use an antiseptic swab to clean the injection port. - Aspirate for blood return.
- Inject the medication.
- perform hand hygiene - ANS-1. perform hand hygiene
2. select the injection port of the IV tubing closest to the client
