ATI CBC Level 1 A w/ rationales UPDATED ACTUAL Questions and
CORRECT Answers
Question: Nurse assessing preschooler with UTI, which of the following findings should the nurse expect?
Correct Answer: Abdominal Pain Rationale: also included constipation, dysuria, foul-smelling urine, and
fever
Question: Nurse is counseling a client who has a family history of colorectal cancer about nutrition
management to help prevent GI cancers. Which image indicates what the nurse should encourage the client
to include liberally in diet?
Correct Answer: Fruit Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day
per female, consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat),
NOT white bread (refined grain products)
Question: A nurse is preparing to extinguish a small fire in clients room. Which of the following actions
should the nurse take when using the fire extinguisher?
Correct Answer: Slide the pin on top of the fire extinguisher straight out Rationale: This allows use of the
extinguisher, should aim at base of the fire, squeeze the handles, sweep from side to side to expel it evenly
(not circular)
Question: A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's
meal tray?
Correct Answer: Oatmeal with raisins Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can
give scrambled eggs, corn (corn flake cereal), and orange juice. This disease can cause diarrhea, weight
loss, abd pain, and fatigue when consuming gluten.
Question: A nurse at a providers office is counseling a client who reports insomnia. Which of the following
statements should the nurse make to include the clients preferences into a sleep promotion plan?
Correct Answer: "Sleep in the location of your home where you feel you rest best" Rationale: encourage
client to sleep where they sleep best (couch, bed, chair), DO NOT consume alcohol in late afternoon or
evening (it can inhibit sleep, if needed consume earlier in the day. DO NOT turn on TV, light and noise at
bedtime can reduce sleep, also Maintain regular sleep and wake times to improve sleep patterns
Question: A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks
the preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the
nurse expect?
Correct Answer: "It's wrong because my dad said I can't kick her" Rationale: The nurse should expect the
preschooler to be motivated to choose right from wrong because of the rules taught to him by his parents.
He will not yet choose right from wrong bc of how his actions affect others (more focused on how will
affect himself)
Question: A nurse in a long term care facility is admitting a new client following a brief stay in acute care.
In adherence with the joint commission national patient safety goals regarding med admin, which of the
following actions should the nurse take?
Correct Answer: Compare a list of the clients current medications with the ones he will take in long-term
care. Rationale: this includes maintaining and communicating Accurate client medication information.
,Question: A nurse is caring for a client who is 2 days post op following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following
actions should the nurse take to treat the clients pain?
Correct Answer: Administer a beta-blocking medication to the client Rationale: These have been shown to
relieve the phantom limb pain manifestations of dull and burning type pain. The nurse should position client
on a firm mattress to prevent hip flexor contractures. Might be able to use heat, ultrasound therapy, or
transcutaneous electrical nerve stimulation for PLP. Bandage should be secured snugly to reduce edema and
promote limb shrinkage. Loosening it will not help PLP.
Question: A nurse is teaching the parent of a toddler about home injury prevention. When discussing
snacks, which of the following statements by the parent indicates an understanding of the teaching?
Correct Answer: "I can give her watermelon pieces after I remove the seeds" Rationale: can easily choke
on seeds or pits. Can easily choke on grapes (peeling them don't help), have to cut grapes into small pieces
before offering them to a toddler, can easily choke on popcorn bc of its tendency to swell and not dissolve
(not putting salt or butter helps nutritionally but not for choking), can easily choke on hot dog slices (slicing
thinly doesn't help)
Question: A nurse is searching electronic databases for clinical research about behavioral indicators of pain
in an infant. Which of the following online sources should the nurse select to research this infant care issue?
Correct Answer: Cumulative Index to Nursing and Allied Health Literature (CINAHL) Rationale: use to
locate clinical research about health-related client care issues.
Question: A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
Correct Answer: Delay the clients meal time if he is fatigued Rationale: To promote safety, the nurse
should encourage the client to rest prior to meal time. If fatigued, give client time to rest. Should instruct to
tilt head forward, avoid using a syringe to force fluids into their mouth, nurse should attempt to eliminate
distractions and disruptions while PT is eating (TV)
Question: A nurse in a long term care facility is performing a fall risk assessment on a newly admitted
client using the timed up and go (TUG) test. The client reports using a tripod cane for ambulation. Which of
the following actions should the nurse take when using this test?
Correct Answer: Observe the client ambulating a distance of 3 m (10 feet) during the TUG test Rationale:
instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. Observe
clients ability and use stopwatch. If longer than 14 seconds then at increased risk for falls. Use assistive aid
if have one. Nurse avoid assisting them to stand. Client should avoid using the arms of the chair for
assistance when standing.
Question: A nurse in an emergency room is caring for an infant who requires emergency surgery. The
infant is accompanied by his 16 year old mother and his maternal grandfather. Which of the following
actions should the nurse take when assisting with informed consent?
Correct Answer: Witness consent obtained from the infants mother. Rationale: The nurse should assist in
obtaining informed consent from the mother by witnessing her signature. A minor even if unemancipated
can provide consent for her infant. They can also legally provide informed consent for STI tx, substance use
tx, and care related to pregnancy in some states. Use the grandparent if legal guardian or if parent is
unavailable. Use court if parent is not acting in child's best interest.
, Question: A nurse is planning care to prevent a catheter-related blood stream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
Correct Answer: Perform hand hygiene before touching the IV tubing. Rationale: hand hygiene before
touching any part of the infusion system or the client to reduce the risk of infection. Change bags of IV
solution every 24 hr, use antimicrobial agents (alcohol, povidone-iodine, or chlorhexidine) NOT hydrogen
peroxide for sure care, check IV site every 4 hr for manifestations of infection at the insertion site
Question: A nurse is caring for an adolescent client who is in critical condition following a MVA in which
he was the passenger. The clients parent shouts at the nurse, asking why her son is dying instead of the
driver. Which of the following actions should the nurse take to provide emotional support to the parent?
Correct Answer: Inform the parent that anger is a natural response when dealing with loss. Rationale:
Nurse should identify that the parent is in the anger stage of grief. Parent should talk to nurse or grief
counselor. Encourage parent to remain in the facility to talk about her feelings and offer a safe environment.
Offer clergy member, don't get clergy without asking first.
Question: A nurse is teaching about advance directives with an older adult client who has a terminal
illness. Which of the following statements should the nurse make?
Correct Answer: "Your advance directives can designate a friend to make your health care decisions"
Rationale: The client can choose anyone to make health care decisions for him if he's unable to. Nurse make
sure that this form is witnessed or notarized according the state law. These are written documents with 1 or
2 witnesses. Next of kin can't change the info on the document even if PT is unconscious.
Question: A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which
of the following statements by the client indicates an understanding of the teaching?
Correct Answer: "I should use a warm paraffin dip for my hands and feet" Rationale: Instruct PT to
maintain healthy weight (limiting purine is for gout not RA bc it breaks down into Uric acid), take warm
shower in morning to help with stiffness and mobility, continue participating in physical activities as
tolerated.
Question: A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the
nurse how to prevent further reactions. Which of the following responses should the nurse make?
Correct Answer: "Wash your child exposed clothing with hot water and detergent" Rationale: flush
exposed skin with water within 15 minutes of exposure, don't scrub it or use antibacterial soap (this will
allow it to spread bc it removes protective skin oils and dilutes the urushiol), touching other kids with it
won't spread it (have to touch the plant)
Question: A nurse is preparing to administer intermittent enteral nutrition via a clients NG tube. In which
order should the nurse take the following actions?
Correct Answer: 1.Assist into high Fowler's (sit them up) 2.Verify tube placement by aspirating 5 mL of
gastric contents 3. Test the aspirate pH 4. Check for gastric residual volume (GRV) (Excessive GRV shows
delayed gastric emptying -at risk for aspiration if more given) 5. Flush the tubing with 30 mL of water (to
ensure the tube is clear and patent)
Question: A nurse is providing change of shift report about a group of clients to the oncoming nurse at the
end of the shift. Which of the following statements should the nurse include?
Correct Answer: "The client has been very tearful since finding out he has diabetes mellitus" Rationale:
nurse should include significant info such as a new dx. Should also identify changes in the clients emotional
status that might indicate a need for additional client support and teaching. Include PRN meds
CORRECT Answers
Question: Nurse assessing preschooler with UTI, which of the following findings should the nurse expect?
Correct Answer: Abdominal Pain Rationale: also included constipation, dysuria, foul-smelling urine, and
fever
Question: Nurse is counseling a client who has a family history of colorectal cancer about nutrition
management to help prevent GI cancers. Which image indicates what the nurse should encourage the client
to include liberally in diet?
Correct Answer: Fruit Rationale: limit alcohol to no more than 2 serving/day for male and 1 serving/day
per female, consume low fat diet (not fried chicken), consume whole grains (oatmeal and whole wheat),
NOT white bread (refined grain products)
Question: A nurse is preparing to extinguish a small fire in clients room. Which of the following actions
should the nurse take when using the fire extinguisher?
Correct Answer: Slide the pin on top of the fire extinguisher straight out Rationale: This allows use of the
extinguisher, should aim at base of the fire, squeeze the handles, sweep from side to side to expel it evenly
(not circular)
Question: A nurse is caring for a child with celiac disease. Which should the nurse remove from the child's
meal tray?
Correct Answer: Oatmeal with raisins Rationale: CANT HAVE GLUTEN (in wheat, rye, and barley) can
give scrambled eggs, corn (corn flake cereal), and orange juice. This disease can cause diarrhea, weight
loss, abd pain, and fatigue when consuming gluten.
Question: A nurse at a providers office is counseling a client who reports insomnia. Which of the following
statements should the nurse make to include the clients preferences into a sleep promotion plan?
Correct Answer: "Sleep in the location of your home where you feel you rest best" Rationale: encourage
client to sleep where they sleep best (couch, bed, chair), DO NOT consume alcohol in late afternoon or
evening (it can inhibit sleep, if needed consume earlier in the day. DO NOT turn on TV, light and noise at
bedtime can reduce sleep, also Maintain regular sleep and wake times to improve sleep patterns
Question: A nurse is assessing the spiritual well-being and development of a preschooler. The nurse asks
the preschooler, "Why is it wrong to kick your baby sister?" Which of the following responses should the
nurse expect?
Correct Answer: "It's wrong because my dad said I can't kick her" Rationale: The nurse should expect the
preschooler to be motivated to choose right from wrong because of the rules taught to him by his parents.
He will not yet choose right from wrong bc of how his actions affect others (more focused on how will
affect himself)
Question: A nurse in a long term care facility is admitting a new client following a brief stay in acute care.
In adherence with the joint commission national patient safety goals regarding med admin, which of the
following actions should the nurse take?
Correct Answer: Compare a list of the clients current medications with the ones he will take in long-term
care. Rationale: this includes maintaining and communicating Accurate client medication information.
,Question: A nurse is caring for a client who is 2 days post op following an above-the-knee amputation. The
client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following
actions should the nurse take to treat the clients pain?
Correct Answer: Administer a beta-blocking medication to the client Rationale: These have been shown to
relieve the phantom limb pain manifestations of dull and burning type pain. The nurse should position client
on a firm mattress to prevent hip flexor contractures. Might be able to use heat, ultrasound therapy, or
transcutaneous electrical nerve stimulation for PLP. Bandage should be secured snugly to reduce edema and
promote limb shrinkage. Loosening it will not help PLP.
Question: A nurse is teaching the parent of a toddler about home injury prevention. When discussing
snacks, which of the following statements by the parent indicates an understanding of the teaching?
Correct Answer: "I can give her watermelon pieces after I remove the seeds" Rationale: can easily choke
on seeds or pits. Can easily choke on grapes (peeling them don't help), have to cut grapes into small pieces
before offering them to a toddler, can easily choke on popcorn bc of its tendency to swell and not dissolve
(not putting salt or butter helps nutritionally but not for choking), can easily choke on hot dog slices (slicing
thinly doesn't help)
Question: A nurse is searching electronic databases for clinical research about behavioral indicators of pain
in an infant. Which of the following online sources should the nurse select to research this infant care issue?
Correct Answer: Cumulative Index to Nursing and Allied Health Literature (CINAHL) Rationale: use to
locate clinical research about health-related client care issues.
Question: A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
Correct Answer: Delay the clients meal time if he is fatigued Rationale: To promote safety, the nurse
should encourage the client to rest prior to meal time. If fatigued, give client time to rest. Should instruct to
tilt head forward, avoid using a syringe to force fluids into their mouth, nurse should attempt to eliminate
distractions and disruptions while PT is eating (TV)
Question: A nurse in a long term care facility is performing a fall risk assessment on a newly admitted
client using the timed up and go (TUG) test. The client reports using a tripod cane for ambulation. Which of
the following actions should the nurse take when using this test?
Correct Answer: Observe the client ambulating a distance of 3 m (10 feet) during the TUG test Rationale:
instruct client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. Observe
clients ability and use stopwatch. If longer than 14 seconds then at increased risk for falls. Use assistive aid
if have one. Nurse avoid assisting them to stand. Client should avoid using the arms of the chair for
assistance when standing.
Question: A nurse in an emergency room is caring for an infant who requires emergency surgery. The
infant is accompanied by his 16 year old mother and his maternal grandfather. Which of the following
actions should the nurse take when assisting with informed consent?
Correct Answer: Witness consent obtained from the infants mother. Rationale: The nurse should assist in
obtaining informed consent from the mother by witnessing her signature. A minor even if unemancipated
can provide consent for her infant. They can also legally provide informed consent for STI tx, substance use
tx, and care related to pregnancy in some states. Use the grandparent if legal guardian or if parent is
unavailable. Use court if parent is not acting in child's best interest.
, Question: A nurse is planning care to prevent a catheter-related blood stream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
Correct Answer: Perform hand hygiene before touching the IV tubing. Rationale: hand hygiene before
touching any part of the infusion system or the client to reduce the risk of infection. Change bags of IV
solution every 24 hr, use antimicrobial agents (alcohol, povidone-iodine, or chlorhexidine) NOT hydrogen
peroxide for sure care, check IV site every 4 hr for manifestations of infection at the insertion site
Question: A nurse is caring for an adolescent client who is in critical condition following a MVA in which
he was the passenger. The clients parent shouts at the nurse, asking why her son is dying instead of the
driver. Which of the following actions should the nurse take to provide emotional support to the parent?
Correct Answer: Inform the parent that anger is a natural response when dealing with loss. Rationale:
Nurse should identify that the parent is in the anger stage of grief. Parent should talk to nurse or grief
counselor. Encourage parent to remain in the facility to talk about her feelings and offer a safe environment.
Offer clergy member, don't get clergy without asking first.
Question: A nurse is teaching about advance directives with an older adult client who has a terminal
illness. Which of the following statements should the nurse make?
Correct Answer: "Your advance directives can designate a friend to make your health care decisions"
Rationale: The client can choose anyone to make health care decisions for him if he's unable to. Nurse make
sure that this form is witnessed or notarized according the state law. These are written documents with 1 or
2 witnesses. Next of kin can't change the info on the document even if PT is unconscious.
Question: A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which
of the following statements by the client indicates an understanding of the teaching?
Correct Answer: "I should use a warm paraffin dip for my hands and feet" Rationale: Instruct PT to
maintain healthy weight (limiting purine is for gout not RA bc it breaks down into Uric acid), take warm
shower in morning to help with stiffness and mobility, continue participating in physical activities as
tolerated.
Question: A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the
nurse how to prevent further reactions. Which of the following responses should the nurse make?
Correct Answer: "Wash your child exposed clothing with hot water and detergent" Rationale: flush
exposed skin with water within 15 minutes of exposure, don't scrub it or use antibacterial soap (this will
allow it to spread bc it removes protective skin oils and dilutes the urushiol), touching other kids with it
won't spread it (have to touch the plant)
Question: A nurse is preparing to administer intermittent enteral nutrition via a clients NG tube. In which
order should the nurse take the following actions?
Correct Answer: 1.Assist into high Fowler's (sit them up) 2.Verify tube placement by aspirating 5 mL of
gastric contents 3. Test the aspirate pH 4. Check for gastric residual volume (GRV) (Excessive GRV shows
delayed gastric emptying -at risk for aspiration if more given) 5. Flush the tubing with 30 mL of water (to
ensure the tube is clear and patent)
Question: A nurse is providing change of shift report about a group of clients to the oncoming nurse at the
end of the shift. Which of the following statements should the nurse include?
Correct Answer: "The client has been very tearful since finding out he has diabetes mellitus" Rationale:
nurse should include significant info such as a new dx. Should also identify changes in the clients emotional
status that might indicate a need for additional client support and teaching. Include PRN meds
