ATI Fundamentals practice Test C
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use to
obtain the temperature? - ANSTemporal
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following
actions should the nurse takes when she observes the client crying? - ANSSit and hold the
client's hand
A community health nurse is preparing a campaign about seasonal influenza. Which of the
following plans should the nurse include as a secondary prevention? - ANSScreening groups of
older adults in nursing care facilities for early influenza manifestations
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching? - ANS"There are
times I should use soap and water rather than an alcohol-based rub to clean my hands."
A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment. - ANS- Inspection
- Auscultation
- Percussion
- Palpation
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve? - ANSSecond intercostal space to the right
of the sternum
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the
following actions should the nurse take? - ANSCount the apical pulse rate for 1 minute, and
describe the rhythm in the chart
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular
size cuff for a client who is obese. Which of the following explanations should the nurse give the
AP? - ANS"Using a cuff that is too small will result in an inaccurately high reading."
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following
actions should the nurse take first? - ANSEvaluate pedal pulses
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first? - ANSPerform hand hygiene
, A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first? - ANSIdentify the client
using two identifiers
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take? - ANSPlace the bladder of the cuff over the posterior aspect of
the thigh
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing technique? - ANSThe nurse washes with her hands held higher than her elbows
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by
an electronic blood pressure machine. The nurse notes the machine begins to measure the
blood pressure at varied intervals and the readings are inconsistent. Which of the following
actions should the nurse take? - ANSDisconnect the machine, and measure the blood pressure
manually every 15 minutes
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take? - ANSRaise the level of the bed
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection. Which of the following actions should the
nurse take? - ANSCarefully remove the gloves and follow with hand hygiene
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both
systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document? - ANSPericardial friction rub
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statement by a group member indicates that the teaching had been effective? - ANS"I
should expect my heart rate to take longer to return to normal after exercise as I get older."
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR? - ANSConfirm unresponsiveness
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements should
the nurse make to the client? - ANS"Donate autologous blood before the surgery."
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea
and who might have a right ear infection. Which of the following routes should the nurse use to
obtain the temperature? - ANSTemporal
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following
actions should the nurse takes when she observes the client crying? - ANSSit and hold the
client's hand
A community health nurse is preparing a campaign about seasonal influenza. Which of the
following plans should the nurse include as a secondary prevention? - ANSScreening groups of
older adults in nursing care facilities for early influenza manifestations
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the
following statements by the AP indicates an understanding of the teaching? - ANS"There are
times I should use soap and water rather than an alcohol-based rub to clean my hands."
A nurse is performing an abdominal assessment for an adult client. Identify the correct
sequence of steps for this assessment. - ANS- Inspection
- Auscultation
- Percussion
- Palpation
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur
related to aortic valve stenosis. At which of the following anatomical areas should the nurse
place the stethoscope to auscultate the aortic valve? - ANSSecond intercostal space to the right
of the sternum
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the
following actions should the nurse take? - ANSCount the apical pulse rate for 1 minute, and
describe the rhythm in the chart
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular
size cuff for a client who is obese. Which of the following explanations should the nurse give the
AP? - ANS"Using a cuff that is too small will result in an inaccurately high reading."
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following
actions should the nurse take first? - ANSEvaluate pedal pulses
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions
should the nurse take first? - ANSPerform hand hygiene
, A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for
the procedure, which of the following actions should the nurse take first? - ANSIdentify the client
using two identifiers
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take? - ANSPlace the bladder of the cuff over the posterior aspect of
the thigh
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing technique? - ANSThe nurse washes with her hands held higher than her elbows
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by
an electronic blood pressure machine. The nurse notes the machine begins to measure the
blood pressure at varied intervals and the readings are inconsistent. Which of the following
actions should the nurse take? - ANSDisconnect the machine, and measure the blood pressure
manually every 15 minutes
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following
actions should the nurse plan to take? - ANSRaise the level of the bed
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.
The client has no documented bloodstream infection. Which of the following actions should the
nurse take? - ANSCarefully remove the gloves and follow with hand hygiene
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. The nurse auscultates a high-pitched scratching sound during both
systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document? - ANSPericardial friction rub
A nurse is teaching a group of older adults about expected changes of aging. Which of the
following statement by a group member indicates that the teaching had been effective? - ANS"I
should expect my heart rate to take longer to return to normal after exercise as I get older."
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR? - ANSConfirm unresponsiveness
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the
next month that might require a blood transfusion. The client expresses concern about the risk
of acquiring an infection from the blood transfusion. Which of the following statements should
the nurse make to the client? - ANS"Donate autologous blood before the surgery."
