1 .A nurse is caring for a client who is scheduled to have his alanine
aminotransferase (ALT) level checked. The client asks the nurse to explain the
laboratory test. Which of the following is an appropriate response by the nurse?
-This test will provide information about the function of your liver
-Rationale: ALT and AST measure your liver function. Creatinine and BUN measure
your kidney function
2. A nurse is caring for a client who has a prescription for morphine 5mg IM
accidentally administers the whole 10 mg from the single-dose vial. Which of the
following actions should the nurse take first?
-Measure the client's respiratory rate.
-Rationale: Morphine can cause respiratory depression. You should ALWAYS ASSESS
the patient first when a med error is performed to make sure med error doesn't put the
client's health in risk.
3. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old
child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral
syrup. Which of the following images shows the correct # of mL the nurse should
administer? (Round the answer to the nearest whole number.)
20 mg x (5mL/12.5mg) = 8 mL
4. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks
when plugging in the IV pump. Which of the following actions should the nurse take
first?
-Unplug the pump.
Rationale: YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire
5. A nurse is caring for a client who has a surgical wound. Which of the following
laboratory values places the client at risk for poor wound healing?
-Serum albumin 3 g/dL
Rationale: Albumin low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client
at risk for poor wound healing.
6 .A nurse is preparing to check a client's blood pressure. Which of the following
actions should the nurse take? Chapter 27 Vitals signs page 244
-Apply the cuff above the client's antecubital fossa
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the
pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above
the antecubital space with the brachial artery in line with the marking on the cuff. Apply
the BP cuff 2.5 cm (1 in) above the antecubital space
7 A nurse is preparing to perform nasal tracheal suctioning for a client. Which of
the following is an appropriate action for the nurse to take? Chapter 53 Airway
management page 563
, -Use surgical asepsis when performing the procedure (book says medical asepsis
which is maybe the same thing)
Rationale: Use surgical asepsis for all types of suctioning. No longer than 10-15
seconds to avoid hypoxemia
8 A nurse is documenting client care. Which of the following abbreviations should
the nurse use?
"BRP" for bathroom privileges
9 A nurse is collecting A blood pressure reading from a client who is sitting in a
chair. The nurse determines that the clients BP is 158/96 mmhg. which of the following
actions should the nurse take?
Recheck the clients BP and her other arm for comparison.
10 A nurse is caring for a client who has left lower atelectasis. in which of the
following positions should the nurse place the client for postural drainage? Chapter 53
Airway Management
Right lateral in Trendelenburg position
11 A nurse is receiving the prescription for a client who is experiencing dysphagia
following a stroke. Which of the following prescriptions should the nurse clarify?
Clear liquids- liquids must be THICK. Clear liquids can cause aspiration
Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically
altered, advanced/ mechanically soft, and regular.
12 A nurse is administering a large volume enema to a client. Identify the sequence
of steps the nurse should follow after preparation and lubricating the enema set
1. Insert the enema tube into the client's rectum
2. Administer the enema solution
3. Clamp the enema tube
4. Remove the enema tube from the clients rectum
5. Wrap the end of the enema tube with a disposable tissue
13 A nurse is inserting an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse take to verify proper placement of the
tube?
Measure the pH of the gastric aspirate.
14 A nurse is teaching a group of newly licensed nurses about the Braden Scale.
Which of the following responses by the newly licensed nurse indicates an
understanding of the teaching?
-"The scale measures six elements."
aminotransferase (ALT) level checked. The client asks the nurse to explain the
laboratory test. Which of the following is an appropriate response by the nurse?
-This test will provide information about the function of your liver
-Rationale: ALT and AST measure your liver function. Creatinine and BUN measure
your kidney function
2. A nurse is caring for a client who has a prescription for morphine 5mg IM
accidentally administers the whole 10 mg from the single-dose vial. Which of the
following actions should the nurse take first?
-Measure the client's respiratory rate.
-Rationale: Morphine can cause respiratory depression. You should ALWAYS ASSESS
the patient first when a med error is performed to make sure med error doesn't put the
client's health in risk.
3. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old
child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral
syrup. Which of the following images shows the correct # of mL the nurse should
administer? (Round the answer to the nearest whole number.)
20 mg x (5mL/12.5mg) = 8 mL
4. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks
when plugging in the IV pump. Which of the following actions should the nurse take
first?
-Unplug the pump.
Rationale: YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire
5. A nurse is caring for a client who has a surgical wound. Which of the following
laboratory values places the client at risk for poor wound healing?
-Serum albumin 3 g/dL
Rationale: Albumin low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client
at risk for poor wound healing.
6 .A nurse is preparing to check a client's blood pressure. Which of the following
actions should the nurse take? Chapter 27 Vitals signs page 244
-Apply the cuff above the client's antecubital fossa
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the
pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above
the antecubital space with the brachial artery in line with the marking on the cuff. Apply
the BP cuff 2.5 cm (1 in) above the antecubital space
7 A nurse is preparing to perform nasal tracheal suctioning for a client. Which of
the following is an appropriate action for the nurse to take? Chapter 53 Airway
management page 563
, -Use surgical asepsis when performing the procedure (book says medical asepsis
which is maybe the same thing)
Rationale: Use surgical asepsis for all types of suctioning. No longer than 10-15
seconds to avoid hypoxemia
8 A nurse is documenting client care. Which of the following abbreviations should
the nurse use?
"BRP" for bathroom privileges
9 A nurse is collecting A blood pressure reading from a client who is sitting in a
chair. The nurse determines that the clients BP is 158/96 mmhg. which of the following
actions should the nurse take?
Recheck the clients BP and her other arm for comparison.
10 A nurse is caring for a client who has left lower atelectasis. in which of the
following positions should the nurse place the client for postural drainage? Chapter 53
Airway Management
Right lateral in Trendelenburg position
11 A nurse is receiving the prescription for a client who is experiencing dysphagia
following a stroke. Which of the following prescriptions should the nurse clarify?
Clear liquids- liquids must be THICK. Clear liquids can cause aspiration
Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically
altered, advanced/ mechanically soft, and regular.
12 A nurse is administering a large volume enema to a client. Identify the sequence
of steps the nurse should follow after preparation and lubricating the enema set
1. Insert the enema tube into the client's rectum
2. Administer the enema solution
3. Clamp the enema tube
4. Remove the enema tube from the clients rectum
5. Wrap the end of the enema tube with a disposable tissue
13 A nurse is inserting an NG tube for a client who requires gastric decompression.
Which of the following actions should the nurse take to verify proper placement of the
tube?
Measure the pH of the gastric aspirate.
14 A nurse is teaching a group of newly licensed nurses about the Braden Scale.
Which of the following responses by the newly licensed nurse indicates an
understanding of the teaching?
-"The scale measures six elements."
