ATI Fundamentals practice Test C
1. 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 Ans: Temporal
2. 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 Ans: Sit
and hold the client's hand
3. A community health nurse is preparing a campaign about seasonal influen- za.
Which of the following plans should the nurse include as a secondary prevention Ans
Screening groups of older adults in nursing care facilities for early influenza
manifestations
4. 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."
5. A nurse is performing an abdominal assessment for an adult client. Identify the
correct sequence of steps for this assessment Ans: - Inspection
- Auscultation
- Percussion
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16
,- Palpation
6. 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 Ans: Second
intercostal space to the right of the sternum
7. 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 Ans: Count the apical pulse rate
for 1 minute, and describe the rhythm in the chart
8. 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."
9. A nurse is admitting a client who has decreased circulation in his left leg. Which
of the following actions should the nurse take first Ans: Evaluate pedal pulses
10. A nurse is preparing to provide tracheostomy care for a client.Which of the
following actions should the nurse take first Ans: Perform hand hygiene
11. 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 Ans: Identify the client using two identifiers
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16
, 12. A nurse is obtaining the blood pressure in a client's lower extremity.Which of the
following actions should the nurse take Ans: Place the bladder of the cuff over the
posterior aspect of the thigh
13. 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 demon- strates proper
surgical hand-washing technique Ans: The nurse washes with her hands held higher
than her elbows
14. 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 Ans: Disconnect the machine,
and measure the blood pressure manually every 15 minutes
15. A nurse is preparing to perform mouth care for an unresponsive client. Which of
the following actions should the nurse plan to take Ans: Raise the level of the bed
16. 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 Ans: Carefully remove the gloves and follow with
hand hygiene
17. A nurse is assessing the heart sounds of a client who has developed chest pain
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16
1. 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 Ans: Temporal
2. 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 Ans: Sit
and hold the client's hand
3. A community health nurse is preparing a campaign about seasonal influen- za.
Which of the following plans should the nurse include as a secondary prevention Ans
Screening groups of older adults in nursing care facilities for early influenza
manifestations
4. 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."
5. A nurse is performing an abdominal assessment for an adult client. Identify the
correct sequence of steps for this assessment Ans: - Inspection
- Auscultation
- Percussion
1/
16
,- Palpation
6. 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 Ans: Second
intercostal space to the right of the sternum
7. 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 Ans: Count the apical pulse rate
for 1 minute, and describe the rhythm in the chart
8. 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."
9. A nurse is admitting a client who has decreased circulation in his left leg. Which
of the following actions should the nurse take first Ans: Evaluate pedal pulses
10. A nurse is preparing to provide tracheostomy care for a client.Which of the
following actions should the nurse take first Ans: Perform hand hygiene
11. 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 Ans: Identify the client using two identifiers
2/
16
, 12. A nurse is obtaining the blood pressure in a client's lower extremity.Which of the
following actions should the nurse take Ans: Place the bladder of the cuff over the
posterior aspect of the thigh
13. 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 demon- strates proper
surgical hand-washing technique Ans: The nurse washes with her hands held higher
than her elbows
14. 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 Ans: Disconnect the machine,
and measure the blood pressure manually every 15 minutes
15. A nurse is preparing to perform mouth care for an unresponsive client. Which of
the following actions should the nurse plan to take Ans: Raise the level of the bed
16. 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 Ans: Carefully remove the gloves and follow with
hand hygiene
17. A nurse is assessing the heart sounds of a client who has developed chest pain
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16
