ATI CBC Level 1 Practice A w/ rationales
Accurate !!
Nurse assessing preschooler with UTI, which of the following findings should the nurse
expect? -ANSWER Abdominal Pain
Rationale: also included constipation, dysuria, foul-smelling urine, and fever
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? -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)
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? -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)
A nurse is caring for a child with celiac disease. Which should the nurse remove from
the child's meal tray? -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.
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? -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
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? -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)
,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? -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.
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? -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.
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? -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)
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? -ANSWER Cumulative Index to Nursing and
Allied Health Literature (CINAHL)
Rationale: use to locate clinical research about health-related client care issues.
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? -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)
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? -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.
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? -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.
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? -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
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? -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.
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? -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.
A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
Accurate !!
Nurse assessing preschooler with UTI, which of the following findings should the nurse
expect? -ANSWER Abdominal Pain
Rationale: also included constipation, dysuria, foul-smelling urine, and fever
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? -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)
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? -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)
A nurse is caring for a child with celiac disease. Which should the nurse remove from
the child's meal tray? -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.
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? -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
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? -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)
,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? -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.
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? -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.
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? -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)
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? -ANSWER Cumulative Index to Nursing and
Allied Health Literature (CINAHL)
Rationale: use to locate clinical research about health-related client care issues.
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? -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)
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? -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.
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? -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.
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? -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
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? -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.
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? -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.
A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates an
