ATI Fundamentals Final Quiz QUESTIONS AND ANSWERS 100% ACCURATE.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which
of the following actions should the nurse take? - Lower the client to the floor and place a pad
under the clients head.
To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a
pillow or other soft object under the client's head.
A home health nurse is planning to provide health promotion activities for a group of clients in
the community. Which of the following activities is an example of the nurse promoting primary
prevention? - Educating clients about the recommended immunization schedule for adults.
Primary prevention includes health education about disease prevention.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates for further
teaching? - The AP hangs the collection bag at the level of the bladder.
The AP should place the drainage bag below the level of the bladder to ensure proper drainage
by gravity.
A nurse is performing a neurological assessment for a client. Which of the following
examinations should the nurse use to check the client's balance? - Romberg Test
When using the Romberg test, the nurse instructs the client to stand with his feet together and
arms at sides, first with his eyes open and then with eyes closed. The inability to maintain
balance is a positive Romberg test.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client? - Washing dishes
Washing dishes requires a low level of activity and is appropriate for this client.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the
following actions should the nurse take? - Repeat each joint motion five times during each
session
To maintain the client's joint mobility the nurse should repeat each motion three to five times.
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric
decompression. Which of the following actions should the nurse include in the plan of care?
(Select all that apply.) - Provide oral hygiene frequently
Measure the amount of drainage from the NG tube every shift
, Secure the NG tube to the client's gown
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which
of the following laboratory findings should the nurse expect? - Decrease calcium
Calcium is necessary for nerve conduction and muscle contractions. When the client's total
calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap
the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a
positive Chvostek's sign and an indication of hypocalcemia.
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following
actions should the nurse take? - Tie the restraint with a quick-release knot
The nurse should use a quick-release knot that can be untied easily in case the client's well-being
requires quickly removing the restraints.
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following
actions should the nurse direct the client to take first? - Remove the safety pin from the
extinguisher
Evidenced-based practice indicates removing the safety pin from the extinguisher is the first
action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct
the client to take first.
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain
and the nurse notes reddish-brown urine in the client's urinary bag. The nurse recognizes these
manifestations as which of the following types of transfusion reaction? - Hemolytic
A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood.
Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion
reaction.
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of
the following assessment findings should the nurse identify as an indication of hypovolemic
shock? - Tachycardia
Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-
carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing
the heart rate and cardiac output, along with increasing the respiratory rate.
A nurse in a provider's office is assessing a client who has heart failure. The client has gained
weight since her last visit and her ankles are edematous. Which of the following findings by the
nurse is another clinical manifestation of fluid volume excess? - Bounding pulse
Bounding pulse is an expected finding of fluid volume excess.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which
of the following actions should the nurse take? - Lower the client to the floor and place a pad
under the clients head.
To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a
pillow or other soft object under the client's head.
A home health nurse is planning to provide health promotion activities for a group of clients in
the community. Which of the following activities is an example of the nurse promoting primary
prevention? - Educating clients about the recommended immunization schedule for adults.
Primary prevention includes health education about disease prevention.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates for further
teaching? - The AP hangs the collection bag at the level of the bladder.
The AP should place the drainage bag below the level of the bladder to ensure proper drainage
by gravity.
A nurse is performing a neurological assessment for a client. Which of the following
examinations should the nurse use to check the client's balance? - Romberg Test
When using the Romberg test, the nurse instructs the client to stand with his feet together and
arms at sides, first with his eyes open and then with eyes closed. The inability to maintain
balance is a positive Romberg test.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client? - Washing dishes
Washing dishes requires a low level of activity and is appropriate for this client.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the
following actions should the nurse take? - Repeat each joint motion five times during each
session
To maintain the client's joint mobility the nurse should repeat each motion three to five times.
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric
decompression. Which of the following actions should the nurse include in the plan of care?
(Select all that apply.) - Provide oral hygiene frequently
Measure the amount of drainage from the NG tube every shift
, Secure the NG tube to the client's gown
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which
of the following laboratory findings should the nurse expect? - Decrease calcium
Calcium is necessary for nerve conduction and muscle contractions. When the client's total
calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap
the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a
positive Chvostek's sign and an indication of hypocalcemia.
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following
actions should the nurse take? - Tie the restraint with a quick-release knot
The nurse should use a quick-release knot that can be untied easily in case the client's well-being
requires quickly removing the restraints.
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following
actions should the nurse direct the client to take first? - Remove the safety pin from the
extinguisher
Evidenced-based practice indicates removing the safety pin from the extinguisher is the first
action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct
the client to take first.
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain
and the nurse notes reddish-brown urine in the client's urinary bag. The nurse recognizes these
manifestations as which of the following types of transfusion reaction? - Hemolytic
A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood.
Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion
reaction.
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of
the following assessment findings should the nurse identify as an indication of hypovolemic
shock? - Tachycardia
Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-
carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing
the heart rate and cardiac output, along with increasing the respiratory rate.
A nurse in a provider's office is assessing a client who has heart failure. The client has gained
weight since her last visit and her ankles are edematous. Which of the following findings by the
nurse is another clinical manifestation of fluid volume excess? - Bounding pulse
Bounding pulse is an expected finding of fluid volume excess.
