ATI NCLEX Fundamentals Assessment 1 questions and
solutions
A nurse is performing blood glucose monitoring for a client. After identifying the client and performing hand hygiene, in
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
what order should the nurse take the following steps?
mi mi mi mi mi mi mi mi mi
A. Apply clean gloves
mi mi mi
B. Hold the client's hand in a dependent position
mi mi mi mi mi mi mi mi
C. Clean the clients finger with an antiseptic
mi mi mi mi mi mi mi
D. Apply the blood to the test strip
mi mi mi mi mi mi mi
E. Have the client wash their hands
mi mi mi mi mi mi
F. Puncture the lateral side of the clients finger to obtain blood - answersCorrect order:
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
E. Have the client wash their hands
mi mi mi mi mi mi
A. Apply clean gloves
mi mi mi
B. Hold the client's hand in a dependent position
mi mi mi mi mi mi mi mi
C. Clean the clients finger with an antiseptic
mi mi mi mi mi mi mi
F. Puncture the lateral side of the clients finger to obtain blood
mi mi mi mi mi mi mi mi mi mi mi
D. Apply the blood to the test strip
mi mi mi mi mi mi mi
--
Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood contamination. Then
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
hold the clients hand in a dependent position to increase blood flow to the fingertips. Do not squeeze the finger! Then cle
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the site, allow it to try. Chose a lateral side to avoid many nerve endings. Puncture the site, wipe away the first drop of blo
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
(has fewer RBC and may have serous fluid), then apply the second drop of blood to the strip.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the following statemen
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
by the client indicates an understanding of the instructions?
mi mi mi mi mi mi mi mi mi
A. "I can sit up in a chair during the feeding"
mi mi mi mi mi mi mi mi mi mi
B. "I'll replace the bag and tubing every week"
mi mi mi mi mi mi mi mi
C. "I'll keep the formula cold until I begin the feeding"
mi mi mi mi mi mi mi mi mi mi
D. "I don't have to worry about the placement of the tube, because my nurses have already checked that" - answersA
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their head raised, sittin
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine, causes aspiration!
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
--
B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do: clean top of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
formula can before opening, avoid touching the opening of the feeding container and other parts of tubing that come in
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
contact with the formula
mi mi mi mi
C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and vomiting.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
D, the caregiver should check the pH level of secretions before feedings
mi mi mi mi mi mi mi mi mi mi mi
A client is reviewing data for a group of clients at the beginning of the shift. For which of the following clients should the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
nurse initiate a dietary referral?
mi mi mi mi mi
A. A client whose BMI is 23
mi mi mi mi mi mi
mimi mimi
,B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids
mi mi mi mi mi mi mi mi mi mi mi
C. A client whose pre-albumin level is 11 mg/dL
mi mi mi mi mi mi mi mi
D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic - answersC
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute nutritional changes!
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
--
A, expected range of BMI is 18.5-24.9
mi mi mi mi mi mi
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid overload. However, th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
does not indicate a need for dietary referral.
mi mi mi mi mi mi mi mi mi
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium levels.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for postpartum care.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Attach identification tags to the body
mi mi mi mi mi mi
B. Remove medical equipment from the body
mi mi mi mi mi mi
C. Cleanse the body while adhering to body-fluid precautions
mi mi mi mi mi mi mi mi
D. Verify the client's organ and tissue donation status
mi mi mi mi mi mi mi mi
E. Confirm that the provider certified and documented the death - answersCorrect order:
mi mi mi mi mi mi mi mi mi mi mi mi
E. Confirm that the provider certified and documented the death
mi mi mi mi mi mi mi mi mi
D. Verify the client's organ and tissue donation status
mi mi mi mi mi mi mi mi
B. Remove medical equipment from the body
mi mi mi mi mi mi
C. Cleanse the body while adhering to body-fluid precautions
mi mi mi mi mi mi mi mi
A. Attach identification tags to the body
mi mi mi mi mi mi
A nurse is caring for a client in a rehabilitation facility. The client says, "I am upset about not being able to attend my churc
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
while living here." Which of the following responses should the nurse make
mi mi mi mi mi mi mi mi mi mi mi mi
A. "Have you attended services at this facility?"
mi mi mi mi mi mi mi
B. "You will be going home soon and can get back to church"
mi mi mi mi mi mi mi mi mi mi mi mi
C. "Perhaps your friend will pick you up for a church service"
mi mi mi mi mi mi mi mi mi mi mi
D. "I would like to hear more about your church" - answersD
mi mi mi mi mi mi mi mi mi mi mi
A nurse is preparing to teach a client who speaks a different language than the nurse about how to perform a dressing
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
change. Which of the following actions should the nurse plan to take
mi mi mi mi mi mi mi mi mi mi mi mi
A. Speak loudly during the teaching session
mi mi mi mi mi mi
B. Request the services of an interpreter
mi mi mi mi mi mi
C. Ask a family member to translate for the client
mi mi mi mi mi mi mi mi mi
D. Simply communicate by asking "yes" or "no" questions - answersB
mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following findings should the nurse
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
expect
mi
A. Positive Chvostek's sign
mi mi mi
B. Positive Trousseau's sign
mi mi mi
C. Diarrhea mi
D. Hyporeflexia - answersD
mi mi mi
Expected calcium range: 9.0-10.5. This pt has hypercalcemia. Manifestations include hyporeflexia, lethargy, fatigue,
mi mi mi mi mi mi mi mi mi mi mi mi
anorexia, confusion, nausea, vomiting, and constipation.
mi mi mi mi mi mi
mimi mimi
solutions
A nurse is performing blood glucose monitoring for a client. After identifying the client and performing hand hygiene, in
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
what order should the nurse take the following steps?
mi mi mi mi mi mi mi mi mi
A. Apply clean gloves
mi mi mi
B. Hold the client's hand in a dependent position
mi mi mi mi mi mi mi mi
C. Clean the clients finger with an antiseptic
mi mi mi mi mi mi mi
D. Apply the blood to the test strip
mi mi mi mi mi mi mi
E. Have the client wash their hands
mi mi mi mi mi mi
F. Puncture the lateral side of the clients finger to obtain blood - answersCorrect order:
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
E. Have the client wash their hands
mi mi mi mi mi mi
A. Apply clean gloves
mi mi mi
B. Hold the client's hand in a dependent position
mi mi mi mi mi mi mi mi
C. Clean the clients finger with an antiseptic
mi mi mi mi mi mi mi
F. Puncture the lateral side of the clients finger to obtain blood
mi mi mi mi mi mi mi mi mi mi mi
D. Apply the blood to the test strip
mi mi mi mi mi mi mi
--
Wash hands first to reduce the presence of micro-organisms. Then apply gloves to prevent blood contamination. Then
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
hold the clients hand in a dependent position to increase blood flow to the fingertips. Do not squeeze the finger! Then cle
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
the site, allow it to try. Chose a lateral side to avoid many nerve endings. Puncture the site, wipe away the first drop of blo
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
(has fewer RBC and may have serous fluid), then apply the second drop of blood to the strip.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is providing discharge instructions to a client who has a new gastrostomy tube. Which of the following statemen
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
by the client indicates an understanding of the instructions?
mi mi mi mi mi mi mi mi mi
A. "I can sit up in a chair during the feeding"
mi mi mi mi mi mi mi mi mi mi
B. "I'll replace the bag and tubing every week"
mi mi mi mi mi mi mi mi
C. "I'll keep the formula cold until I begin the feeding"
mi mi mi mi mi mi mi mi mi mi
D. "I don't have to worry about the placement of the tube, because my nurses have already checked that" - answersA
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
The clients head should be elevated at 30-45 degrees during the feeding. They can be in bed with their head raised, sittin
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
in a chair, or ambulating as long as their head is at 30-45 degrees. Never be supine, causes aspiration!
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
--
B, the tubing and bag should be replaced every 24 hours to prevent bacterial growth. Other things to do: clean top of
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
formula can before opening, avoid touching the opening of the feeding container and other parts of tubing that come in
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
contact with the formula
mi mi mi mi
C, enteral formula should be kept at room temperature! Cold causes gastric gramps, nausea,and vomiting.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
D, the caregiver should check the pH level of secretions before feedings
mi mi mi mi mi mi mi mi mi mi mi
A client is reviewing data for a group of clients at the beginning of the shift. For which of the following clients should the
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
nurse initiate a dietary referral?
mi mi mi mi mi
A. A client whose BMI is 23
mi mi mi mi mi mi
mimi mimi
,B. A client who gained 1.8kg (4lbs) overnight after receiving IV fluids
mi mi mi mi mi mi mi mi mi mi mi
C. A client whose pre-albumin level is 11 mg/dL
mi mi mi mi mi mi mi mi
D. A client who has a sodium level of 140 mEq/L after taking a thiazide diuretic - answersC
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
Expected range of pre-albumin is 15-36. Pre-albumin is one of the most reliable indicators of acute nutritional changes!
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
--
A, expected range of BMI is 18.5-24.9
mi mi mi mi mi mi
B, the weight gain is due to IV fluids and should be reported to the provider and be monitor for fluid overload. However, th
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
does not indicate a need for dietary referral.
mi mi mi mi mi mi mi mi mi
D, expected range of sodium is 135-145. A patient taking a thiazide diuretic is at risk for low sodium levels.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A nurse is caring for a client who has died. Identify the sequence of steps the nurse should follow for postpartum care.
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
A. Attach identification tags to the body
mi mi mi mi mi mi
B. Remove medical equipment from the body
mi mi mi mi mi mi
C. Cleanse the body while adhering to body-fluid precautions
mi mi mi mi mi mi mi mi
D. Verify the client's organ and tissue donation status
mi mi mi mi mi mi mi mi
E. Confirm that the provider certified and documented the death - answersCorrect order:
mi mi mi mi mi mi mi mi mi mi mi mi
E. Confirm that the provider certified and documented the death
mi mi mi mi mi mi mi mi mi
D. Verify the client's organ and tissue donation status
mi mi mi mi mi mi mi mi
B. Remove medical equipment from the body
mi mi mi mi mi mi
C. Cleanse the body while adhering to body-fluid precautions
mi mi mi mi mi mi mi mi
A. Attach identification tags to the body
mi mi mi mi mi mi
A nurse is caring for a client in a rehabilitation facility. The client says, "I am upset about not being able to attend my churc
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
while living here." Which of the following responses should the nurse make
mi mi mi mi mi mi mi mi mi mi mi mi
A. "Have you attended services at this facility?"
mi mi mi mi mi mi mi
B. "You will be going home soon and can get back to church"
mi mi mi mi mi mi mi mi mi mi mi mi
C. "Perhaps your friend will pick you up for a church service"
mi mi mi mi mi mi mi mi mi mi mi
D. "I would like to hear more about your church" - answersD
mi mi mi mi mi mi mi mi mi mi mi
A nurse is preparing to teach a client who speaks a different language than the nurse about how to perform a dressing
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
change. Which of the following actions should the nurse plan to take
mi mi mi mi mi mi mi mi mi mi mi mi
A. Speak loudly during the teaching session
mi mi mi mi mi mi
B. Request the services of an interpreter
mi mi mi mi mi mi
C. Ask a family member to translate for the client
mi mi mi mi mi mi mi mi mi
D. Simply communicate by asking "yes" or "no" questions - answersB
mi mi mi mi mi mi mi mi mi mi
A nurse is assessing a client who has a calcium level of 11.2 mg/dL. Which of the following findings should the nurse
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
expect
mi
A. Positive Chvostek's sign
mi mi mi
B. Positive Trousseau's sign
mi mi mi
C. Diarrhea mi
D. Hyporeflexia - answersD
mi mi mi
Expected calcium range: 9.0-10.5. This pt has hypercalcemia. Manifestations include hyporeflexia, lethargy, fatigue,
mi mi mi mi mi mi mi mi mi mi mi mi
anorexia, confusion, nausea, vomiting, and constipation.
mi mi mi mi mi mi
mimi mimi
