ATI NCLEX Fundamentals Assessment 1
A charge nurse in the CCU is reviewing prescriptions for a group of clients. The nurse should
identify that which of the following procedures are outside the nurse's scope of practice
A. Drawing blood from an arterial line
B. How to calculate a Glasgow Coma Scale score C. Injecting an antibiotic into the body D.
providing a client with type 1 diabetes with initial education - ANS-C Medication is injected
directly into the spinal cord's intrathecal space during an intrathecal injection. Injections that are
intradermal, subcutaneous, intramuscular, and intravenous are within a nurse's scope of
practice. A charge nurse is observing another nurse perform a sterile dressing change on a
client. Which of the following actions should the charge nurse identify as a contaminant to the
sterile field
A. Placing a surgical mask on a client who is coughing
B. Placing sterile supplies within a 1cm (0.4in) border of the sterile field
C. Using sterile forceps to move the items on the sterile field
D. Positioning the sterile tray on the beside table 1cm (0.4in) above waist level - ANS-B
The nurse should place objects toward the center of the sterile field and away from the 2.5cm
(1 in) border around the drap
A client is reviewing data for a group of clients at the beginning of the shift. The nurse should
initiate a dietary referral for which of the following patients: A. A customer with a BMI of 23 B. A
client who gained 1.8kg (4lbs) overnight after receiving IV fluids
C. A client whose pre-albumin level is 11 mg/dL
D. A patient who has taken a thiazide diuretic and has a sodium level of 140 mEq/L - ANS-C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of
acute nutritional changes!
--
A, the expected BMI range is from 18.5-24.9 B, the IV fluids are to blame for the weight gain,
which should be reported to the provider and monitored for fluid overload. However, this does
not indicate a need for dietary referral.
D, the expected sodium range is 135-145. A patient taking a thiazide diuretic is at risk for low
sodium levels.
When repositioning a client who has recently suffered a stroke in their bed, a home health
nurse is instructing the client's caregiver on proper body mechanics. The nurse should include
which of the following instructions in the instruction. (Select all that apply)
A. Elevate the bed to the height of your waist
B. Elevate the head of the bed before you move the client up in bed
C. Stand with your feet wide apart
D. Look in the direction of the movement. E. Keep your knees bent - ANS-A, C, D ,E
--
The patient should be flat to reduce the risk for injury for the caregiver
, A nurse enters a client's room and sees the client on the floor next to the bed. The nurse
should proceed with which of the following actions first. A. Assist the client back into bed
B. Inform the manager of the risk. C. Obtain the client's vital signs
D. Complete the ANS-C incident report regarding the client's fall. A nurse in an acute care
facility is caring for a client who has confusion and continually pulls at her medical tubes and
devices. Which of the following actions should the nurse take first
A. Obtain a written prescription to apply wrist restraints to the client
B. Apply a stockinette dressing to conceal the client's IV
C. Administer the lowest possible dose of an IV sedative to the client
D. Telephone family members to advise them that the client might require restraints - ANS-B
Use least restrictive intervention first!
A nurse in an assisted living facility observes that an older adult client who was previously
socially interactive appears withdrawn and avoids the other residents. Which of the following
actions should the nurse take first
A. Assess the client for a loss of hearing
B. Arrange transportation for the client to an outside senior activity program
C. Encourage visits from family members and friends
D. Plan a recreational activity for the client with a small group of residents - ANS-A
A nurse in the PACU is caring for a client following abdominal surgery. Which of the following
actions should the nurse take first
A. Monitor the client's oxygen saturation level
B. Assess the client's pain level
C. Reinforce the surgical dressing for the patient. D. ANS-A: Check the client's urine output.
Injury caused by an obstruction to the patient's airway poses the greatest threat. A nurse is
administering a tuberculin test by the intradermal route to a client. Which of the following steps
should the nurse take?
A. Before inserting the needle into the client's skin, pinch the skin to slightly elevate the tissue.
B. Hold the bevel of the needle pointing downward when piercing the skin
C. Insert the needle at a 10 degree angle to the skin
D. Massage the site for a few seconds after removing the needle to distribute the medication
evenly - ANS-C
Insert the needle at a 5-15 degree angle to deposit the medication in the dermis
A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following
findings should the nurse expect
A. Positive Chvostek's sign
B. Positive Trousseau's sign
C. Diarrhea
D. Hyporeflexia - ANS-D
Expected calcium range: 9.0-10.5. Hypercalcemia affects this patient. Hyporeflexia, lethargy,
fatigue, anorexia, confusion, nausea, vomiting, and constipation are some of the symptoms. --
A,positive chvostek sign is a sign of hypocalcemia. When the nurse taps the client's cheek in
front of the ear, it is perceived as a facial muscle contracture. B, the positive trousseau sign is a
sign of low magnesium and low calcium. Seen as a spasm of the hand that occurs when the
nurse decreases the patients blood supply by inflating the blood pressure cuff
A charge nurse in the CCU is reviewing prescriptions for a group of clients. The nurse should
identify that which of the following procedures are outside the nurse's scope of practice
A. Drawing blood from an arterial line
B. How to calculate a Glasgow Coma Scale score C. Injecting an antibiotic into the body D.
providing a client with type 1 diabetes with initial education - ANS-C Medication is injected
directly into the spinal cord's intrathecal space during an intrathecal injection. Injections that are
intradermal, subcutaneous, intramuscular, and intravenous are within a nurse's scope of
practice. A charge nurse is observing another nurse perform a sterile dressing change on a
client. Which of the following actions should the charge nurse identify as a contaminant to the
sterile field
A. Placing a surgical mask on a client who is coughing
B. Placing sterile supplies within a 1cm (0.4in) border of the sterile field
C. Using sterile forceps to move the items on the sterile field
D. Positioning the sterile tray on the beside table 1cm (0.4in) above waist level - ANS-B
The nurse should place objects toward the center of the sterile field and away from the 2.5cm
(1 in) border around the drap
A client is reviewing data for a group of clients at the beginning of the shift. The nurse should
initiate a dietary referral for which of the following patients: A. A customer with a BMI of 23 B. A
client who gained 1.8kg (4lbs) overnight after receiving IV fluids
C. A client whose pre-albumin level is 11 mg/dL
D. A patient who has taken a thiazide diuretic and has a sodium level of 140 mEq/L - ANS-C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of
acute nutritional changes!
--
A, the expected BMI range is from 18.5-24.9 B, the IV fluids are to blame for the weight gain,
which should be reported to the provider and monitored for fluid overload. However, this does
not indicate a need for dietary referral.
D, the expected sodium range is 135-145. A patient taking a thiazide diuretic is at risk for low
sodium levels.
When repositioning a client who has recently suffered a stroke in their bed, a home health
nurse is instructing the client's caregiver on proper body mechanics. The nurse should include
which of the following instructions in the instruction. (Select all that apply)
A. Elevate the bed to the height of your waist
B. Elevate the head of the bed before you move the client up in bed
C. Stand with your feet wide apart
D. Look in the direction of the movement. E. Keep your knees bent - ANS-A, C, D ,E
--
The patient should be flat to reduce the risk for injury for the caregiver
, A nurse enters a client's room and sees the client on the floor next to the bed. The nurse
should proceed with which of the following actions first. A. Assist the client back into bed
B. Inform the manager of the risk. C. Obtain the client's vital signs
D. Complete the ANS-C incident report regarding the client's fall. A nurse in an acute care
facility is caring for a client who has confusion and continually pulls at her medical tubes and
devices. Which of the following actions should the nurse take first
A. Obtain a written prescription to apply wrist restraints to the client
B. Apply a stockinette dressing to conceal the client's IV
C. Administer the lowest possible dose of an IV sedative to the client
D. Telephone family members to advise them that the client might require restraints - ANS-B
Use least restrictive intervention first!
A nurse in an assisted living facility observes that an older adult client who was previously
socially interactive appears withdrawn and avoids the other residents. Which of the following
actions should the nurse take first
A. Assess the client for a loss of hearing
B. Arrange transportation for the client to an outside senior activity program
C. Encourage visits from family members and friends
D. Plan a recreational activity for the client with a small group of residents - ANS-A
A nurse in the PACU is caring for a client following abdominal surgery. Which of the following
actions should the nurse take first
A. Monitor the client's oxygen saturation level
B. Assess the client's pain level
C. Reinforce the surgical dressing for the patient. D. ANS-A: Check the client's urine output.
Injury caused by an obstruction to the patient's airway poses the greatest threat. A nurse is
administering a tuberculin test by the intradermal route to a client. Which of the following steps
should the nurse take?
A. Before inserting the needle into the client's skin, pinch the skin to slightly elevate the tissue.
B. Hold the bevel of the needle pointing downward when piercing the skin
C. Insert the needle at a 10 degree angle to the skin
D. Massage the site for a few seconds after removing the needle to distribute the medication
evenly - ANS-C
Insert the needle at a 5-15 degree angle to deposit the medication in the dermis
A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following
findings should the nurse expect
A. Positive Chvostek's sign
B. Positive Trousseau's sign
C. Diarrhea
D. Hyporeflexia - ANS-D
Expected calcium range: 9.0-10.5. Hypercalcemia affects this patient. Hyporeflexia, lethargy,
fatigue, anorexia, confusion, nausea, vomiting, and constipation are some of the symptoms. --
A,positive chvostek sign is a sign of hypocalcemia. When the nurse taps the client's cheek in
front of the ear, it is perceived as a facial muscle contracture. B, the positive trousseau sign is a
sign of low magnesium and low calcium. Seen as a spasm of the hand that occurs when the
nurse decreases the patients blood supply by inflating the blood pressure cuff
