ATI & NCLEX REVIEW/ TEST 1
1. A charge nurse is assigning rooms for clients to be admitted to the unit. To prevent
falls, which of the following clients should the nurse assign to the room closest to the
nurses' station?
A. A middle adult who is postoperative following laparoscopic cholecystectomy
B. A middle adult who requires telemetry for a possible myocardial infarction
C. A young adult who is postoperative following an open reduction internal fixation of
the ankle
D. An older adult who is postoperative following a below the knee amputation
Answer: D. An older adult who is postoperative following a below the knee
amputation
2. A client has been diagnosed with a terminal illness and is crying. What statement
made by the nurse is a barrier for further communication?
A. Everything will be okay. It is out of your hands.
B. I am here if you would like to talk
C. Is there anything I can do for you or questions that I can answer?
D. This must be difficult for you
Answer: A. Everything will be okay. It is out of your hands.
3. A client has been involved in a motor vehicle crash and has multiple injuries. What
guiding principles of Florence Nightingale would assist this client's recuperation and
health maintenance? Select all that apply.
A. Clean air and water
B. Cleanliness
C. Blood administration
D. Light
E. Efficient drainage
Answer: A. Clean air and water, B. Cleanliness, D. Light, E. Efficient drainage
4. A client is admitted to the acute care facility with a suspected case of malaria.
What question is priority?
A. Have you had unprotected sex?
B. Have you recently traveled out of the country?
C. What medications are you taking?
D. Do you take any street drugs?
Answer: B. Have you recently traveled outside of the country?
5. A client is going to have a surgical procedure. What intervention provided by the
nurse can help the client feel safe and aid in postoperative recovery?
A. Explain the procedure before surgery
B. Inform the client that they will be alright
,C. Call a family member prior to the client entering the surgical suite
D. Make sure all insurance information has been obtained
Answer: A. Explain the procedure before surgery
6. A client is having abdominal pain. What open-ended statement can the nurse use
to find out more about the client's condition?
A. Tell me more about how you feel
B. Rate your pain on a scale of 1 to 10
C. Point with one finger where your pain is located
D. What medications are you taking?
Answer: A. Tell me more about how you feel
7. A client is suspected to be infected with methicillin-resistant Staphylococcus
aureus (MRSA) in a sacral wound. What precautions should the nurse be sure are
followed during wound care?
A. Droplet
B. Contact
C. Airborne
D. Standard
Answer: B. Contact
8. A client no longer requires care in the coronary intensive care unit after coronary
artery bypass graft surgery. Where should the nurse prepare to transfer the client?
A. Sub-acute or Step-down unit
B. Skilled care unit
C. Medical floor
D. Long-term care
Answer: A. Sub-acute or Step-down unit
9. A client that is home bound requires long-term intravenous antibiotic therapy. The
insurance company refuses to keep the client in the hospital during this treatment
regimen. What service would best meet the needs of the client?
A. Hospice
B. Respite care
C. Home healthcare
D. Telehealth
Answer: C. Home healthcare
10. A client with diabetes asks the nurse, "If I can't do heavy exercise, what's the
point in exercising?" What responses by the nurse can encourage the client to
perform moderate exercise? Select all that apply.
A. It will prevent the use of insulin
B. It will prevent cancer
C. It will enhance energy levels
,D. It will reduce stress
E. It will provide relaxation
Answer: C. It will enhance energy levels, D. It will reduce stress, E. It will provide
relaxation
11. A high school student interested in becoming a nurse asks the nursing instructor
what the role of the LPN/LVN is. What is the BEST response by the instructor?
A. The LPN/LVN provides bedside care
B. The LPN/LVN develops the plan of care for clients
C. The LPN/LVN performs wound care
D. The LPN/LVN supervises registered nurses (RNs)
Answer: A. The LPN/LVN provides bedside care
12. A Muslim-Arab female client is in the clinic for a gynecologic procedure. The
client does not directly look at the nurse or physician in the eye when speaking.
What does the nurse interpret this behavior to mean?
A. The client does not trust the caregivers
B. The client is demonstrating modesty
C. The client believes she has a sexually transmitted infection
D. The client has been sexually abused
Answer: B. The client is demonstrating modesty
13. A nurse caring for a 20-year-old client who is sexually active and has come to the
college health clinic for a first-time check-up. Which of the following interventions
should the nurse perform first to determine the client's need for health promotion and
disease prevention?
A. Measure vital signs
B. Encourage HIV screening
C. Determine risk factors
D. Instruct client to use condoms
Answer: C. Determine risk factors
14. A nurse caring for a client who has a history of falls. Which of the following
actions is the nurse's priority?
A. Complete fall risk assessment
B. Educate the client and family about fall risks
C. Eliminate safety hazards from the client's environment
D. Make sure the client uses assistive aids in his possession
Answer: A. Complete fall risk assessment
15. A nurse caring for a client who is a Jehovah's Witness and is scheduled for
surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood
transfusion is essential. The client refuses based on his religious values. Which of
the following responses should the nurse make?
, A. "I believe in this case you should really make an exception and accept the blood
transfusion."
B. "I know your family would approve of your decision to have a blood transfusion."
C. "Why does your religion mandate that you cannot receive any blood
transfusions?"
D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual
leaders and come to a reasonable solution."
Answer: D. "Let's discuss the necessity for a blood transfusion with your religious
and spiritual leaders and come to a reasonable solution."
16. A nurse caring for a competent adult client who tells the nurse that he is thinking
about leaving the hospital against medical advice. The nurse believes this is not in
the client's best interest and prepares to administer a PRN sedative medication the
client has not requested. Which of the following types of tort is the nurse about to
commit?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
Answer: B. False imprisonment
17. A nurse discovers that a neighbor is a client on the unit in which the nurse works,
although the nurse is not assigned to care for that client. The nurse accesses the
EMR to find out the client's diagnosis. What action may clients take if they are aware
of this type of incident?
A. Report the incident as a HIPAA violation
B. Sue the nurse for libel
C. Sue the nurse for negligence
D. Report the nurse for defamation
Answer: A. Report the incident as a HIPAA violation
18. A nurse has noticed several occasions in the past week when another nurse on
the unit seemed drowsy and unable to focus. Today, she found the nurse asleep in a
chair in the break room when she was not on break. Which of the following actions
should the nurse take?
A. Alert the American Nurse Association
B. Fill out an incident report
C. Report the observation to the nurse manager on the unit
D. Leave the nurse alone to sleep
Answer: C. Report the observation to the nurse manager on the unit
19. A nurse has prepared a sterile field for assisting a provider with a chest tube
insertion. Which of the following events should the nurse recognize as contaminating
the sterile field? Select all that apply.
1. A charge nurse is assigning rooms for clients to be admitted to the unit. To prevent
falls, which of the following clients should the nurse assign to the room closest to the
nurses' station?
A. A middle adult who is postoperative following laparoscopic cholecystectomy
B. A middle adult who requires telemetry for a possible myocardial infarction
C. A young adult who is postoperative following an open reduction internal fixation of
the ankle
D. An older adult who is postoperative following a below the knee amputation
Answer: D. An older adult who is postoperative following a below the knee
amputation
2. A client has been diagnosed with a terminal illness and is crying. What statement
made by the nurse is a barrier for further communication?
A. Everything will be okay. It is out of your hands.
B. I am here if you would like to talk
C. Is there anything I can do for you or questions that I can answer?
D. This must be difficult for you
Answer: A. Everything will be okay. It is out of your hands.
3. A client has been involved in a motor vehicle crash and has multiple injuries. What
guiding principles of Florence Nightingale would assist this client's recuperation and
health maintenance? Select all that apply.
A. Clean air and water
B. Cleanliness
C. Blood administration
D. Light
E. Efficient drainage
Answer: A. Clean air and water, B. Cleanliness, D. Light, E. Efficient drainage
4. A client is admitted to the acute care facility with a suspected case of malaria.
What question is priority?
A. Have you had unprotected sex?
B. Have you recently traveled out of the country?
C. What medications are you taking?
D. Do you take any street drugs?
Answer: B. Have you recently traveled outside of the country?
5. A client is going to have a surgical procedure. What intervention provided by the
nurse can help the client feel safe and aid in postoperative recovery?
A. Explain the procedure before surgery
B. Inform the client that they will be alright
,C. Call a family member prior to the client entering the surgical suite
D. Make sure all insurance information has been obtained
Answer: A. Explain the procedure before surgery
6. A client is having abdominal pain. What open-ended statement can the nurse use
to find out more about the client's condition?
A. Tell me more about how you feel
B. Rate your pain on a scale of 1 to 10
C. Point with one finger where your pain is located
D. What medications are you taking?
Answer: A. Tell me more about how you feel
7. A client is suspected to be infected with methicillin-resistant Staphylococcus
aureus (MRSA) in a sacral wound. What precautions should the nurse be sure are
followed during wound care?
A. Droplet
B. Contact
C. Airborne
D. Standard
Answer: B. Contact
8. A client no longer requires care in the coronary intensive care unit after coronary
artery bypass graft surgery. Where should the nurse prepare to transfer the client?
A. Sub-acute or Step-down unit
B. Skilled care unit
C. Medical floor
D. Long-term care
Answer: A. Sub-acute or Step-down unit
9. A client that is home bound requires long-term intravenous antibiotic therapy. The
insurance company refuses to keep the client in the hospital during this treatment
regimen. What service would best meet the needs of the client?
A. Hospice
B. Respite care
C. Home healthcare
D. Telehealth
Answer: C. Home healthcare
10. A client with diabetes asks the nurse, "If I can't do heavy exercise, what's the
point in exercising?" What responses by the nurse can encourage the client to
perform moderate exercise? Select all that apply.
A. It will prevent the use of insulin
B. It will prevent cancer
C. It will enhance energy levels
,D. It will reduce stress
E. It will provide relaxation
Answer: C. It will enhance energy levels, D. It will reduce stress, E. It will provide
relaxation
11. A high school student interested in becoming a nurse asks the nursing instructor
what the role of the LPN/LVN is. What is the BEST response by the instructor?
A. The LPN/LVN provides bedside care
B. The LPN/LVN develops the plan of care for clients
C. The LPN/LVN performs wound care
D. The LPN/LVN supervises registered nurses (RNs)
Answer: A. The LPN/LVN provides bedside care
12. A Muslim-Arab female client is in the clinic for a gynecologic procedure. The
client does not directly look at the nurse or physician in the eye when speaking.
What does the nurse interpret this behavior to mean?
A. The client does not trust the caregivers
B. The client is demonstrating modesty
C. The client believes she has a sexually transmitted infection
D. The client has been sexually abused
Answer: B. The client is demonstrating modesty
13. A nurse caring for a 20-year-old client who is sexually active and has come to the
college health clinic for a first-time check-up. Which of the following interventions
should the nurse perform first to determine the client's need for health promotion and
disease prevention?
A. Measure vital signs
B. Encourage HIV screening
C. Determine risk factors
D. Instruct client to use condoms
Answer: C. Determine risk factors
14. A nurse caring for a client who has a history of falls. Which of the following
actions is the nurse's priority?
A. Complete fall risk assessment
B. Educate the client and family about fall risks
C. Eliminate safety hazards from the client's environment
D. Make sure the client uses assistive aids in his possession
Answer: A. Complete fall risk assessment
15. A nurse caring for a client who is a Jehovah's Witness and is scheduled for
surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood
transfusion is essential. The client refuses based on his religious values. Which of
the following responses should the nurse make?
, A. "I believe in this case you should really make an exception and accept the blood
transfusion."
B. "I know your family would approve of your decision to have a blood transfusion."
C. "Why does your religion mandate that you cannot receive any blood
transfusions?"
D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual
leaders and come to a reasonable solution."
Answer: D. "Let's discuss the necessity for a blood transfusion with your religious
and spiritual leaders and come to a reasonable solution."
16. A nurse caring for a competent adult client who tells the nurse that he is thinking
about leaving the hospital against medical advice. The nurse believes this is not in
the client's best interest and prepares to administer a PRN sedative medication the
client has not requested. Which of the following types of tort is the nurse about to
commit?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality
Answer: B. False imprisonment
17. A nurse discovers that a neighbor is a client on the unit in which the nurse works,
although the nurse is not assigned to care for that client. The nurse accesses the
EMR to find out the client's diagnosis. What action may clients take if they are aware
of this type of incident?
A. Report the incident as a HIPAA violation
B. Sue the nurse for libel
C. Sue the nurse for negligence
D. Report the nurse for defamation
Answer: A. Report the incident as a HIPAA violation
18. A nurse has noticed several occasions in the past week when another nurse on
the unit seemed drowsy and unable to focus. Today, she found the nurse asleep in a
chair in the break room when she was not on break. Which of the following actions
should the nurse take?
A. Alert the American Nurse Association
B. Fill out an incident report
C. Report the observation to the nurse manager on the unit
D. Leave the nurse alone to sleep
Answer: C. Report the observation to the nurse manager on the unit
19. A nurse has prepared a sterile field for assisting a provider with a chest tube
insertion. Which of the following events should the nurse recognize as contaminating
the sterile field? Select all that apply.
