ATI fundamentals practice A
On a scale from 0 to 10, a postoperative client describes their pain verbally. The client's
comprehension of the preoperative instruction regarding pain management should the nurse
look for in which of the following statements? 1. Since my pain medication isn't helping, I think I
should take it more often. 2. "I'll be able to distract myself from the pain by taking a more rapid
breath." 3. "It might help me to listen to music while I'm lying in bed."
4. "Due to some pain, I don't want to walk today." - ANS-3 For the management of mild pain,
listening to music is an effective nonpharmacological treatment. A client with a gastrostomy tube
is having a follow-up visit with a home health nurse. The client receives medications and
intermittent feedings through the tube. The client recently developed diarrhea. The nurse
should choose which of the following as a possible cause of the diarrhea. 1. The formula is
being given to the customer at room temperature. 2. The feedings infuse at a slow, continuous
drip over 8 hr each night.
3. Once every 24 hours, the client's caregiver cleans the feeding bag with warm water. 4. The
client's caregiver flushes the tubing with water before and after administering medications. -
ANS-3
Feeding bags should be washed out after each feeding and replaced with a new feeding bag
every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with
the client's caregiver to avoid future contamination.
A nurse who is taking care of a patient who has had a knee arthroplasty and needs to wear
sequential compression sleeves that are the length of their thighs. Which of the following actions
should the nurse take?
1. Get the client into a prone position with your help. 2. Place a sleeve over the top of each leg
with the opening at the knee.
3. Verify that two fingers can fit through the sleeves. 4. ANS-3: Set the ankle pressure to 65
mm Hg. The nurse should ensure that there is enough space for two fingers to fit under the
sleeve because any less space between the sleeves and the legs can inhibit circulation when
the sleeves inflate.
A nurse in a long-term care facility is caring for a client who dies during the nurses shift.
Identify the sequence in which the nurse should perform the following steps
1. Place a name tag on the body
2. Obtained the provider's death notification. 3. Remove the tubes and indwelling lines
4. Wash the clients body
5. Ask the client's family if they want to see the body - ANS-2,3,4,5,1 A client who is recovering
from surgery and suffers from a deficit in fluid volume is receiving 1 liter of 0.9% sodium chloride
from a nurse. Which of the following changes should the nurse identify as an indication that the
treatment was successful?
1. Increase in hematocrit
2. Increase in respiratory rate
3. Decrease in heart rate
, 4. Decrease in capillary refill time - ANS-3
Fluid volume deficit causes tachycardia. The heart rate should return to the expected range if
the imbalance is corrected. A nurse is administering an otic medication to an older adult client.
To ensure that the medication reaches the inner ear, which of the following actions should the
nurse take? 1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min. - ANS-1
The medication will be more easily absorbed into the inner ear if you gently press on the tragus
of the ear. A nurse is admitting a client who has an abdominal wound with a large amount of
purulent drainage. Which of the following types of transmission precautions should the nurse
initiate?
1. environment that is safe 2. Airborne precautions
3. Droplet precautions
4. Precautions for contact - ANS-4 Major wound infections require contact precautions, which
means the nurse should admit the client to a private room. All caregivers should wear a gown
and gloves during direct contact with this client.
A patient with an exacerbation of heart failure is admitted by a nurse. In planning this clients
care, when should the nurse initiate discharge planning?
1. Throughout the admissions procedure 2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family - ANS-1
Discharge planning should begin as soon as the client is undergoing the admission process.
The nurse should begin to assess the client's needs and plan for care both during and after the
client's time in the facility.
A new patient is being admitted by a nurse. Which of the following actions should the nurse
take while performing medication reconciliation?
1. Verify the client's name on their identification bracelet with the medication administration
record.
2. Call the pharmacy to determine whether the client's medications are available.
3. Compare the client's home medications with the provider's prescriptions.
4. Place the client's home medication bottles in a secure location. - ANS-3
The nurse should compare the client's home medications with the provider's prescriptions when
performing medication reconciliation.
A client who has been on bed rest for the past month is being evaluated by a nurse. Which of
the following findings should the nurse identify as an indication that the client has developed
thrombophlebitis?
1. Bladder distention
2. Decreased blood pressure
3. Calf cramping 4. ANS-3: diminished bowel sounds A common complication of immobility is
thrombophlebitis, which manifests as calf muscle swelling, redness, and tenderness. A nurse is
assessing a client who reports increased pain following physical therapy. When determining the
level of the patient's pain, which of the following should the nurse inquire about? 1. "Is your pain
constant or intermittent?"
On a scale from 0 to 10, a postoperative client describes their pain verbally. The client's
comprehension of the preoperative instruction regarding pain management should the nurse
look for in which of the following statements? 1. Since my pain medication isn't helping, I think I
should take it more often. 2. "I'll be able to distract myself from the pain by taking a more rapid
breath." 3. "It might help me to listen to music while I'm lying in bed."
4. "Due to some pain, I don't want to walk today." - ANS-3 For the management of mild pain,
listening to music is an effective nonpharmacological treatment. A client with a gastrostomy tube
is having a follow-up visit with a home health nurse. The client receives medications and
intermittent feedings through the tube. The client recently developed diarrhea. The nurse
should choose which of the following as a possible cause of the diarrhea. 1. The formula is
being given to the customer at room temperature. 2. The feedings infuse at a slow, continuous
drip over 8 hr each night.
3. Once every 24 hours, the client's caregiver cleans the feeding bag with warm water. 4. The
client's caregiver flushes the tubing with water before and after administering medications. -
ANS-3
Feeding bags should be washed out after each feeding and replaced with a new feeding bag
every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with
the client's caregiver to avoid future contamination.
A nurse who is taking care of a patient who has had a knee arthroplasty and needs to wear
sequential compression sleeves that are the length of their thighs. Which of the following actions
should the nurse take?
1. Get the client into a prone position with your help. 2. Place a sleeve over the top of each leg
with the opening at the knee.
3. Verify that two fingers can fit through the sleeves. 4. ANS-3: Set the ankle pressure to 65
mm Hg. The nurse should ensure that there is enough space for two fingers to fit under the
sleeve because any less space between the sleeves and the legs can inhibit circulation when
the sleeves inflate.
A nurse in a long-term care facility is caring for a client who dies during the nurses shift.
Identify the sequence in which the nurse should perform the following steps
1. Place a name tag on the body
2. Obtained the provider's death notification. 3. Remove the tubes and indwelling lines
4. Wash the clients body
5. Ask the client's family if they want to see the body - ANS-2,3,4,5,1 A client who is recovering
from surgery and suffers from a deficit in fluid volume is receiving 1 liter of 0.9% sodium chloride
from a nurse. Which of the following changes should the nurse identify as an indication that the
treatment was successful?
1. Increase in hematocrit
2. Increase in respiratory rate
3. Decrease in heart rate
, 4. Decrease in capillary refill time - ANS-3
Fluid volume deficit causes tachycardia. The heart rate should return to the expected range if
the imbalance is corrected. A nurse is administering an otic medication to an older adult client.
To ensure that the medication reaches the inner ear, which of the following actions should the
nurse take? 1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min. - ANS-1
The medication will be more easily absorbed into the inner ear if you gently press on the tragus
of the ear. A nurse is admitting a client who has an abdominal wound with a large amount of
purulent drainage. Which of the following types of transmission precautions should the nurse
initiate?
1. environment that is safe 2. Airborne precautions
3. Droplet precautions
4. Precautions for contact - ANS-4 Major wound infections require contact precautions, which
means the nurse should admit the client to a private room. All caregivers should wear a gown
and gloves during direct contact with this client.
A patient with an exacerbation of heart failure is admitted by a nurse. In planning this clients
care, when should the nurse initiate discharge planning?
1. Throughout the admissions procedure 2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family - ANS-1
Discharge planning should begin as soon as the client is undergoing the admission process.
The nurse should begin to assess the client's needs and plan for care both during and after the
client's time in the facility.
A new patient is being admitted by a nurse. Which of the following actions should the nurse
take while performing medication reconciliation?
1. Verify the client's name on their identification bracelet with the medication administration
record.
2. Call the pharmacy to determine whether the client's medications are available.
3. Compare the client's home medications with the provider's prescriptions.
4. Place the client's home medication bottles in a secure location. - ANS-3
The nurse should compare the client's home medications with the provider's prescriptions when
performing medication reconciliation.
A client who has been on bed rest for the past month is being evaluated by a nurse. Which of
the following findings should the nurse identify as an indication that the client has developed
thrombophlebitis?
1. Bladder distention
2. Decreased blood pressure
3. Calf cramping 4. ANS-3: diminished bowel sounds A common complication of immobility is
thrombophlebitis, which manifests as calf muscle swelling, redness, and tenderness. A nurse is
assessing a client who reports increased pain following physical therapy. When determining the
level of the patient's pain, which of the following should the nurse inquire about? 1. "Is your pain
constant or intermittent?"
