ESTUDYR
ATI RN CONCEPT BASED ASSESSMENT LEVEL 3 PRACTICE
A MOST TESTED QUESTIONS AND ANSWERS GRADED A+
WITH RATIONALES
1. A client with end-stage kidney failure decides to stop hemodialysis. As the client’s advocate, the
nurse should:
A. Persuade the client to continue therapy
B. Arrange a family conference to override the decision
C. Support the client’s informed decision (✔ )
D. Notify the provider to mandate continuation
Rationale: Advocacy means upholding the client’s autonomous health care choices.
2. A nurse infuses 0.9% sodium chloride 1 L over 4 hr instead of 8 hr. The appropriate documentation
is:
A. “Infusion completed early; no harm evident.”
B. “0.9% NaCl 1 L IV infused over 4 hr. Vital signs stable.” (✔ )
C. “Infusion rate error—notify provider.”
D. “Client tolerated increased rate—no ill effects.”
Rationale: Document volume, actual time, and client status without judgment.
3. For a child with increased ICP, the nurse should:
A. Keep head turned to one side
B. Maintain head in midline position (✔ )
C. Elevate knees above hips
D. Provide routine suctioning
Rationale: Midline head positioning promotes cerebral venous drainage and prevents ICP spikes.
4. Signs of increased intracranial pressure include (select all):
1. Sleepiness
2. Widening pulse pressure
,ESTUDYR
3. Decerebrate posturing
4. Hypothermia
A. 1 and 4
B. 1, 2, and 3 (✔ )
C. 2 and 4
D. All four
Rationale: Sleepiness, widened pulse pressure, and decerebrate posturing are classic ICP indicators.
5. A client mourning hair loss before chemotherapy tells the nurse her feelings. The FIRST nursing
action is to:
A. Explain wig fitting options
B. Assess the importance of hair loss to the client (✔ )
C. Provide emotional support pamphlets
D. Refer to a support group
Rationale: Assessment is the initial step to tailor supportive interventions.
6. A client in stage 4 Alzheimer’s disease most likely exhibits:
A. Wandering behaviors
B. Inability to manage finances (✔ )
C. Severe language loss
D. Total dependence for ADLs
Rationale: Stage 4 includes decreased complex task performance, like financial management.
7. A child with spastic cerebral palsy will demonstrate:
A. Hypotonia
B. Ataxia
C. Fine and gross motor skill challenges (✔ )
D. Tremors
Rationale: Spastic CP is characterized by stiff muscles affecting coordination and skill.
, ESTUDYR
8. A client’s IV site shows pain and a red streak. The nurse’s first action is to:
A. Elevate the extremity
B. Slow the infusion rate
C. Discontinue the infusion (✔ )
D. Apply warm compress
Rationale: Phlebitis risk mandates immediate IV discontinuation to prevent further injury.
9. A discharging client requests home wound supplies. For cost-effective care, the nurse should
provide:
A. One week’s worth
B. Enough for 1–2 days (✔ )
C. No supplies; refer to pharmacy
D. Supplies for one month
Rationale: Short‐term provision ensures safe discharge but limits cost burden.
10. A therapeutic outcome for baclofen in a spinal cord injury is:
A. Increased deep tendon reflexes
B. Decreased flexor and extensor spasticity (✔ )
C. Improved sensation in limbs
D. Elevated blood pressure
Rationale: Baclofen reduces muscle spasm, improving comfort and function.
11. After below-knee amputation, a client selects pinto beans when asking about complete proteins.
The nurse should:
A. Encourage high-fat meats
B. Explain that pinto beans are incomplete proteins (✔ )
C. Praise the choice
D. Suggest citrus fruit
Rationale: Plant proteins often lack some essential amino acids; meats or dairy supply complete
proteins.
ATI RN CONCEPT BASED ASSESSMENT LEVEL 3 PRACTICE
A MOST TESTED QUESTIONS AND ANSWERS GRADED A+
WITH RATIONALES
1. A client with end-stage kidney failure decides to stop hemodialysis. As the client’s advocate, the
nurse should:
A. Persuade the client to continue therapy
B. Arrange a family conference to override the decision
C. Support the client’s informed decision (✔ )
D. Notify the provider to mandate continuation
Rationale: Advocacy means upholding the client’s autonomous health care choices.
2. A nurse infuses 0.9% sodium chloride 1 L over 4 hr instead of 8 hr. The appropriate documentation
is:
A. “Infusion completed early; no harm evident.”
B. “0.9% NaCl 1 L IV infused over 4 hr. Vital signs stable.” (✔ )
C. “Infusion rate error—notify provider.”
D. “Client tolerated increased rate—no ill effects.”
Rationale: Document volume, actual time, and client status without judgment.
3. For a child with increased ICP, the nurse should:
A. Keep head turned to one side
B. Maintain head in midline position (✔ )
C. Elevate knees above hips
D. Provide routine suctioning
Rationale: Midline head positioning promotes cerebral venous drainage and prevents ICP spikes.
4. Signs of increased intracranial pressure include (select all):
1. Sleepiness
2. Widening pulse pressure
,ESTUDYR
3. Decerebrate posturing
4. Hypothermia
A. 1 and 4
B. 1, 2, and 3 (✔ )
C. 2 and 4
D. All four
Rationale: Sleepiness, widened pulse pressure, and decerebrate posturing are classic ICP indicators.
5. A client mourning hair loss before chemotherapy tells the nurse her feelings. The FIRST nursing
action is to:
A. Explain wig fitting options
B. Assess the importance of hair loss to the client (✔ )
C. Provide emotional support pamphlets
D. Refer to a support group
Rationale: Assessment is the initial step to tailor supportive interventions.
6. A client in stage 4 Alzheimer’s disease most likely exhibits:
A. Wandering behaviors
B. Inability to manage finances (✔ )
C. Severe language loss
D. Total dependence for ADLs
Rationale: Stage 4 includes decreased complex task performance, like financial management.
7. A child with spastic cerebral palsy will demonstrate:
A. Hypotonia
B. Ataxia
C. Fine and gross motor skill challenges (✔ )
D. Tremors
Rationale: Spastic CP is characterized by stiff muscles affecting coordination and skill.
, ESTUDYR
8. A client’s IV site shows pain and a red streak. The nurse’s first action is to:
A. Elevate the extremity
B. Slow the infusion rate
C. Discontinue the infusion (✔ )
D. Apply warm compress
Rationale: Phlebitis risk mandates immediate IV discontinuation to prevent further injury.
9. A discharging client requests home wound supplies. For cost-effective care, the nurse should
provide:
A. One week’s worth
B. Enough for 1–2 days (✔ )
C. No supplies; refer to pharmacy
D. Supplies for one month
Rationale: Short‐term provision ensures safe discharge but limits cost burden.
10. A therapeutic outcome for baclofen in a spinal cord injury is:
A. Increased deep tendon reflexes
B. Decreased flexor and extensor spasticity (✔ )
C. Improved sensation in limbs
D. Elevated blood pressure
Rationale: Baclofen reduces muscle spasm, improving comfort and function.
11. After below-knee amputation, a client selects pinto beans when asking about complete proteins.
The nurse should:
A. Encourage high-fat meats
B. Explain that pinto beans are incomplete proteins (✔ )
C. Praise the choice
D. Suggest citrus fruit
Rationale: Plant proteins often lack some essential amino acids; meats or dairy supply complete
proteins.
