ATI NCLEX Fundamentals Assessment 1
questions and answers 2024\2025 A+
Grade
A nurse is performing blood glucose monitoring for a client. After identifying the client and performing
hand hygiene, in what order should the nurse take the following steps?
A. Apply clean gloves
B. Hold the client's hand in a dependent position
C. Clean the clients finger with an antiseptic
D. Apply the blood to the test strip
E. Have the client wash their hands
F. Puncture the lateral side of the clients finger to obtain blood
- correct answer Correct order:
E. Have the client wash their hands
A. Apply clean gloves
B. Hold the client's hand in a dependent position
C. Clean the clients finger with an antiseptic
F. Puncture the lateral side of the clients finger to obtain blood
D. Apply the blood to the test strip
,--
Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood
contamination. Then hold the clients hand in a dependent position to increase blood flow to the
fingertips. Do not squeeze the finger! Then clean the site, allow it to try. Chose a lateral side to avoid
many nerve endings. Puncture the site, wipe away the first drop of blood (has fewer RBC and may have
serous fluid), then apply the second drop of blood to the strip.
A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the
following statements by the client indicates an understanding of the instructions?
A. "I can sit up in a chair during the feeding"
B. "I'll replace the bag and tubing every week"
C. "I'll keep the formula cold until I begin the feeding"
D. "I don't have to worry about the placement of the tube, because my nurses have already checked
that"
- correct answer A
The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their
head raised, sitting in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine,
causes aspiration!
--
B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do:
clean top of formula can before opening, avoid touching the opening of the feeding container and other
parts of tubing that come in contact with the formula
C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and
vomiting.
D, the caregiver should check the pH level of secretions before feedings
A client is reviewing data for a group of clients at the beginning of the shift. For which of the following
clients should the nurse initiate a dietary referral?
A. A client whose BMI is 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 client who has a sodium level of 140 mEq/L after taking a thiazide diuretic
- correct answer C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute
nutritional changes!
--
A, expected range of BMI is 18.5-24.9
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid
overload. However, this does not indicate a need for dietary referral.
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium
levels.
A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for
postpartum care.
A. Attach identification tags to the body
B. Remove medical equipment from the body
C. Cleanse the body while adhering to body-fluid precautions
D. Verify the client's organ and tissue donation status
E. Confirm that the provider certified and documented the death
- correct answer Correct order:
E. Confirm that the provider certified and documented the death
D. Verify the client's organ and tissue donation status
B. Remove medical equipment from the body
C. Cleanse the body while adhering to body-fluid precautions
A. Attach identification tags to the body
questions and answers 2024\2025 A+
Grade
A nurse is performing blood glucose monitoring for a client. After identifying the client and performing
hand hygiene, in what order should the nurse take the following steps?
A. Apply clean gloves
B. Hold the client's hand in a dependent position
C. Clean the clients finger with an antiseptic
D. Apply the blood to the test strip
E. Have the client wash their hands
F. Puncture the lateral side of the clients finger to obtain blood
- correct answer Correct order:
E. Have the client wash their hands
A. Apply clean gloves
B. Hold the client's hand in a dependent position
C. Clean the clients finger with an antiseptic
F. Puncture the lateral side of the clients finger to obtain blood
D. Apply the blood to the test strip
,--
Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood
contamination. Then hold the clients hand in a dependent position to increase blood flow to the
fingertips. Do not squeeze the finger! Then clean the site, allow it to try. Chose a lateral side to avoid
many nerve endings. Puncture the site, wipe away the first drop of blood (has fewer RBC and may have
serous fluid), then apply the second drop of blood to the strip.
A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the
following statements by the client indicates an understanding of the instructions?
A. "I can sit up in a chair during the feeding"
B. "I'll replace the bag and tubing every week"
C. "I'll keep the formula cold until I begin the feeding"
D. "I don't have to worry about the placement of the tube, because my nurses have already checked
that"
- correct answer A
The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their
head raised, sitting in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine,
causes aspiration!
--
B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do:
clean top of formula can before opening, avoid touching the opening of the feeding container and other
parts of tubing that come in contact with the formula
C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and
vomiting.
D, the caregiver should check the pH level of secretions before feedings
A client is reviewing data for a group of clients at the beginning of the shift. For which of the following
clients should the nurse initiate a dietary referral?
A. A client whose BMI is 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 client who has a sodium level of 140 mEq/L after taking a thiazide diuretic
- correct answer C
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute
nutritional changes!
--
A, expected range of BMI is 18.5-24.9
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid
overload. However, this does not indicate a need for dietary referral.
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium
levels.
A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for
postpartum care.
A. Attach identification tags to the body
B. Remove medical equipment from the body
C. Cleanse the body while adhering to body-fluid precautions
D. Verify the client's organ and tissue donation status
E. Confirm that the provider certified and documented the death
- correct answer Correct order:
E. Confirm that the provider certified and documented the death
D. Verify the client's organ and tissue donation status
B. Remove medical equipment from the body
C. Cleanse the body while adhering to body-fluid precautions
A. Attach identification tags to the body
