ne
tz
sh
ne
ATI CMS FUNDAMENTALS – QUESTIONS ANDla
ANSWERS
tz
sh
Sp
ne
A nurse is caring for a client who is in the terminal stage of cancer. Which of
la
the following actions should the nurse take when she observes the client
tz
sh
crying?
Sp
A. Contact the family and ask them to stay with the client
ne
B. Offer to call the client's minister
la
C. Sit and hold the client's hand
tz
sh
D. Leave the room and allow the client to cry privately Correct Ans - C. Sit
Sp
and hold the client's hand
ne
la
A nurse is caring for a client who requires wrist restraints. Which of the
tz
following actions should the nurse take?
sh
Sp
A. Tie a secure knot with the restraint straps
ne
B. Attach the restraints' straps to the bed's side rails
la
C. Make sure 3 fingers fit beneath the restraints
tz
D. Remove the restraints at least every 2 hrs Correct Ans - D. Remove the
sh
Sp
restraints at least every 2 hrs
ne
la
After collecting data on a client's radial pulses, the nurse documents "radial
tz
pulses 4+ bilaterally." This finding indicates which of the following pulse
sh
Sp
qualities?
ne
A. Bounding
la
B. Full
tz
C. Variable
sh
Sp
D. Weak Correct Ans - A. Bounding
ne
la
A nurse is reinforcing teaching with a client regarding protein intake. Which
tz
of the following foods should the nurse include as an example of an
sh
Sp
incomplete protein?
ne
A. Eggs
la
B. Soybeans
tz
C. Lentils
sh
Sp
D. Yogurt Correct Ans - C. Lentils
ne
la
A nurse is planning weight loss strategies for a group of clients who are
tz
obese. Which of the following actions by the nurse will improve the clients'
sh
Sp
commitment to a long-term goal of weight loss?
ne
A. Attempting to increase the clients' self-motivation
la
B. Keeping detailed records of each client's progress
tz
C. Testing client learning after each teaching session
sh
Sp
D. Avoiding discussing topics that might cause client anxiety Correct Ans -
ne
A. Attempting to increase the clients' self-motivation
la
sh
Sp
la
Sp
, ne
tz
sh
ne
la
A nurse is reinforcing teaching with a client who is using a patient-controlled
tz
analgesia (PA) pump to deliver morphine for pain management. Which of the
sh
Sp
following statements should the nurse identify as an indication that the client
understands the instructions?
ne
la
C A. "l'Il limit pushing the button so I don't get an overdose."
tz
B. "If I push the button and still have pain after 2 minutes, I'll push it again."
sh
Sp
C. "I'll ask my niece to push the button when I am sleeping."
ne
D. "I can still use my TENS unit even though I'm pushing the PCA button."
Correct Ans - D. "I can still use my TENS unit even though I'm pushing the
la
tz
PCA button."
sh
Sp
ne
A nurse is caring for a client who had a stroke and is at risk of falling. Which
of the following actions should the nurse take?
la
tz
A. Assign the client to a private room
sh
B. Keep 4 side rails up while the client is in bed
Sp
ne
C. Monitor the client at least once every hour
D. Request a PRN prescription for restraints Correct Ans - C. Monitor the
la
tz
client at least once every hour
sh
Sp
ne
A nurse is caring for a client who has a history of dysrhythmias. Upon
entering the room, the nurse discovers client is unresponsive to verbal or
la
painful stimuli, has no respirations, and is pulseless. Which of the following
tz
sh
actions should the nurse take first?
Sp
ne
A. Start chest compressions
B. Provide breaths with a manual resuscitation bag
la
C. Administer oxygen
tz
D. Establish an airway Correct Ans - A. Start chest compressions
sh
Sp
ne
A nurse is collecting data from a client. Which of the following statements by
la
the nurse reflects the communication technique of clarifying?
tz
sh
A. "Now that we have talked about your medications, let's talk about your
Sp
pain."
ne
B. "Are you having other symptoms?"
la
C. "It sounds like your pain is intermittent."
tz
sh
D. "It seems as though you have really had a rough time these past few
Sp
weeks." Correct Ans - C. "It sounds like your pain is intermittent."
ne
la
A nurse is obtaining the blood pressure in a client's lower extremity. Which of
tz
sh
the following actions should the nurse take?
Sp
A. Auscultate for the blood pressure at the dorsalis pedis artery
ne
B. Measure the blood pressure with the client sitting on the side of the bed
la
C. Place the cuff 7.6 cm (3 in) above the popliteal artery
tz
sh
D. Place the bladder of the cuff over the posterior aspect of the thigh Correct
Sp
Ans - D. Place the bladder of the cuff over the posterior aspect of the thigh
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
A nurse is reinforcing teaching with a preschooler about how to use a
la
metered-dose inhaler. Which of the following methods should the nurse use
tz
during this instructional session?
sh
Sp
A. A simple demonstration of inhaler use
ne
B. A discussion of health problems
la
C. Collaboration in instruction
tz
D. Mutual goal-setting Correct Ans - A. A simple demonstration of inhaler
sh
Sp
use
ne
A nurse is reinforcing teaching for a client who has a new prescription for
la
tz
home oxygen therapy. Which of the following instructions should the nurse
sh
Sp
include?
ne
A. Do not use any electrical devices when receiving oxygen
B. Keep the oxygen tank lying on the floor when there is any risk of knocking
la
tz
it over
sh
C. Do not use any materials containing oil or alcohol when using oxygen
Sp
ne
D. Use synthetic blankets and clothing when using oxygen Correct Ans -
C. Do not use any materials containing oil or alcohol when using oxygen
la
tz
sh
A nurse is caring for a client who has major fecal incontinence and reports
Sp
ne
irritation in the perianal area. Which of the following actions should the nurse
take first?
la
A. Apply a fecal collection system
tz
sh
B. Apply a barrier cream
Sp
ne
C. Cleanse and dry the area
D. Check the client's perineum Correct Ans - D. Check the client's
la
perineum
tz
sh
Sp
A nurse is preparing to insert an NG tube for a client who has a bowel
ne
obstruction. Which of the following actions should the nurse take first?
la
A. Provide the client with a glass of water
tz
sh
B. Assist the client into a sitting position
Sp
C. Explain the procedure to the client
ne
D. Measure the length of tubing to be inserted Correct Ans - C. Explain the
la
procedure to the client
tz
sh
Sp
A nurse is preparing to measure a client's blood pressure with a
ne
sphygmomanometer and a stethoscope. Which of the following actions
la
should the nurse take?
tz
sh
A. Wrap the cuff loosely around the client's arm
Sp
B. Use a cuff with a bladder that encircles 60% of the client's upper arm
ne
C. Place the cuff so its lower edge is 1.3 cm (0.5 in) above the antecubital
la
space
tz
sh
D. Have the client place both feet flat on the floor Correct Ans - D. Have
Sp
the client place both feet flat on the floor
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
A nurse is reinforcing teaching with a client about how to obtain a capillary
la
finger-stick blood sample. Which of the following actions by the client
tz
requires the nurse to intervene?
sh
Sp
A. Elevates the finger above heart level
ne
B. Rubs the fingertip with an alcohol pad
la
C. Punctures the side of the fingertip
tz
D. Wraps the finger in a warm cloth Correct Ans - A. Elevates the finger
sh
Sp
above heart level
ne
A nurse is collecting data from a client who has fluid-volume excess. Which of
la
tz
the following findings should the nurse expect?
sh
Sp
A. Crackles in the lung fields
ne
B. Flat neck veins
C. Postural hypotension
la
tz
D. Dark yellow urine Correct Ans - A. Crackles in the lung fields
sh
Sp
ne
A nurse is caring for a client who states that she does not want to get out of
bed due to pain from arthritis. Which of the following actions should the
la
tz
nurse take?
sh
A. Tell the client the provider does not want her to remain in bed
Sp
ne
B. Allow the client to remain in bed until her pain subsides
C. Instruct the family to perform ADLs for the client
la
D. Advise the client to perform range-of-motion exercises while in bed
tz
sh
Correct Ans - D. Advise the client to perform range-of-motion exercises
Sp
ne
while in bed
la
A nurse is administering 3 liquid medications through a client's nasogastric
tz
tube. Which of the following actions should the nurse take?
sh
Sp
A. Position the head of the client's bed at 15 degrees®
ne
B. Mix the medications together in a medication cup
la
C. Pour the medications into the enteral formula container
tz
sh
D. Flush the tube with water before and after instilling each medication
Sp
Correct Ans - D. Flush the tube with water before and after instilling each
ne
medication
la
tz
sh
A nurse enters a client's room and finds the client sitting on the floor and
Sp
leaning against the side of the bed. The client states she slipped while
ne
getting out of bed. Which of the following actions should the nurse take first?
la
A. Complete an incident report
tz
sh
B. Check the client for injuries
Sp
C. Make sure the client has skid-free footwear
ne
D. Remind the client to ask for help with getting out of bed Correct Ans -
la
B. Check the client for injuries
tz
sh
Sp
ne
la
sh
Sp
la
Sp
tz
sh
ne
ATI CMS FUNDAMENTALS – QUESTIONS ANDla
ANSWERS
tz
sh
Sp
ne
A nurse is caring for a client who is in the terminal stage of cancer. Which of
la
the following actions should the nurse take when she observes the client
tz
sh
crying?
Sp
A. Contact the family and ask them to stay with the client
ne
B. Offer to call the client's minister
la
C. Sit and hold the client's hand
tz
sh
D. Leave the room and allow the client to cry privately Correct Ans - C. Sit
Sp
and hold the client's hand
ne
la
A nurse is caring for a client who requires wrist restraints. Which of the
tz
following actions should the nurse take?
sh
Sp
A. Tie a secure knot with the restraint straps
ne
B. Attach the restraints' straps to the bed's side rails
la
C. Make sure 3 fingers fit beneath the restraints
tz
D. Remove the restraints at least every 2 hrs Correct Ans - D. Remove the
sh
Sp
restraints at least every 2 hrs
ne
la
After collecting data on a client's radial pulses, the nurse documents "radial
tz
pulses 4+ bilaterally." This finding indicates which of the following pulse
sh
Sp
qualities?
ne
A. Bounding
la
B. Full
tz
C. Variable
sh
Sp
D. Weak Correct Ans - A. Bounding
ne
la
A nurse is reinforcing teaching with a client regarding protein intake. Which
tz
of the following foods should the nurse include as an example of an
sh
Sp
incomplete protein?
ne
A. Eggs
la
B. Soybeans
tz
C. Lentils
sh
Sp
D. Yogurt Correct Ans - C. Lentils
ne
la
A nurse is planning weight loss strategies for a group of clients who are
tz
obese. Which of the following actions by the nurse will improve the clients'
sh
Sp
commitment to a long-term goal of weight loss?
ne
A. Attempting to increase the clients' self-motivation
la
B. Keeping detailed records of each client's progress
tz
C. Testing client learning after each teaching session
sh
Sp
D. Avoiding discussing topics that might cause client anxiety Correct Ans -
ne
A. Attempting to increase the clients' self-motivation
la
sh
Sp
la
Sp
, ne
tz
sh
ne
la
A nurse is reinforcing teaching with a client who is using a patient-controlled
tz
analgesia (PA) pump to deliver morphine for pain management. Which of the
sh
Sp
following statements should the nurse identify as an indication that the client
understands the instructions?
ne
la
C A. "l'Il limit pushing the button so I don't get an overdose."
tz
B. "If I push the button and still have pain after 2 minutes, I'll push it again."
sh
Sp
C. "I'll ask my niece to push the button when I am sleeping."
ne
D. "I can still use my TENS unit even though I'm pushing the PCA button."
Correct Ans - D. "I can still use my TENS unit even though I'm pushing the
la
tz
PCA button."
sh
Sp
ne
A nurse is caring for a client who had a stroke and is at risk of falling. Which
of the following actions should the nurse take?
la
tz
A. Assign the client to a private room
sh
B. Keep 4 side rails up while the client is in bed
Sp
ne
C. Monitor the client at least once every hour
D. Request a PRN prescription for restraints Correct Ans - C. Monitor the
la
tz
client at least once every hour
sh
Sp
ne
A nurse is caring for a client who has a history of dysrhythmias. Upon
entering the room, the nurse discovers client is unresponsive to verbal or
la
painful stimuli, has no respirations, and is pulseless. Which of the following
tz
sh
actions should the nurse take first?
Sp
ne
A. Start chest compressions
B. Provide breaths with a manual resuscitation bag
la
C. Administer oxygen
tz
D. Establish an airway Correct Ans - A. Start chest compressions
sh
Sp
ne
A nurse is collecting data from a client. Which of the following statements by
la
the nurse reflects the communication technique of clarifying?
tz
sh
A. "Now that we have talked about your medications, let's talk about your
Sp
pain."
ne
B. "Are you having other symptoms?"
la
C. "It sounds like your pain is intermittent."
tz
sh
D. "It seems as though you have really had a rough time these past few
Sp
weeks." Correct Ans - C. "It sounds like your pain is intermittent."
ne
la
A nurse is obtaining the blood pressure in a client's lower extremity. Which of
tz
sh
the following actions should the nurse take?
Sp
A. Auscultate for the blood pressure at the dorsalis pedis artery
ne
B. Measure the blood pressure with the client sitting on the side of the bed
la
C. Place the cuff 7.6 cm (3 in) above the popliteal artery
tz
sh
D. Place the bladder of the cuff over the posterior aspect of the thigh Correct
Sp
Ans - D. Place the bladder of the cuff over the posterior aspect of the thigh
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
A nurse is reinforcing teaching with a preschooler about how to use a
la
metered-dose inhaler. Which of the following methods should the nurse use
tz
during this instructional session?
sh
Sp
A. A simple demonstration of inhaler use
ne
B. A discussion of health problems
la
C. Collaboration in instruction
tz
D. Mutual goal-setting Correct Ans - A. A simple demonstration of inhaler
sh
Sp
use
ne
A nurse is reinforcing teaching for a client who has a new prescription for
la
tz
home oxygen therapy. Which of the following instructions should the nurse
sh
Sp
include?
ne
A. Do not use any electrical devices when receiving oxygen
B. Keep the oxygen tank lying on the floor when there is any risk of knocking
la
tz
it over
sh
C. Do not use any materials containing oil or alcohol when using oxygen
Sp
ne
D. Use synthetic blankets and clothing when using oxygen Correct Ans -
C. Do not use any materials containing oil or alcohol when using oxygen
la
tz
sh
A nurse is caring for a client who has major fecal incontinence and reports
Sp
ne
irritation in the perianal area. Which of the following actions should the nurse
take first?
la
A. Apply a fecal collection system
tz
sh
B. Apply a barrier cream
Sp
ne
C. Cleanse and dry the area
D. Check the client's perineum Correct Ans - D. Check the client's
la
perineum
tz
sh
Sp
A nurse is preparing to insert an NG tube for a client who has a bowel
ne
obstruction. Which of the following actions should the nurse take first?
la
A. Provide the client with a glass of water
tz
sh
B. Assist the client into a sitting position
Sp
C. Explain the procedure to the client
ne
D. Measure the length of tubing to be inserted Correct Ans - C. Explain the
la
procedure to the client
tz
sh
Sp
A nurse is preparing to measure a client's blood pressure with a
ne
sphygmomanometer and a stethoscope. Which of the following actions
la
should the nurse take?
tz
sh
A. Wrap the cuff loosely around the client's arm
Sp
B. Use a cuff with a bladder that encircles 60% of the client's upper arm
ne
C. Place the cuff so its lower edge is 1.3 cm (0.5 in) above the antecubital
la
space
tz
sh
D. Have the client place both feet flat on the floor Correct Ans - D. Have
Sp
the client place both feet flat on the floor
ne
la
sh
Sp
la
Sp
, ne
tz
sh
ne
A nurse is reinforcing teaching with a client about how to obtain a capillary
la
finger-stick blood sample. Which of the following actions by the client
tz
requires the nurse to intervene?
sh
Sp
A. Elevates the finger above heart level
ne
B. Rubs the fingertip with an alcohol pad
la
C. Punctures the side of the fingertip
tz
D. Wraps the finger in a warm cloth Correct Ans - A. Elevates the finger
sh
Sp
above heart level
ne
A nurse is collecting data from a client who has fluid-volume excess. Which of
la
tz
the following findings should the nurse expect?
sh
Sp
A. Crackles in the lung fields
ne
B. Flat neck veins
C. Postural hypotension
la
tz
D. Dark yellow urine Correct Ans - A. Crackles in the lung fields
sh
Sp
ne
A nurse is caring for a client who states that she does not want to get out of
bed due to pain from arthritis. Which of the following actions should the
la
tz
nurse take?
sh
A. Tell the client the provider does not want her to remain in bed
Sp
ne
B. Allow the client to remain in bed until her pain subsides
C. Instruct the family to perform ADLs for the client
la
D. Advise the client to perform range-of-motion exercises while in bed
tz
sh
Correct Ans - D. Advise the client to perform range-of-motion exercises
Sp
ne
while in bed
la
A nurse is administering 3 liquid medications through a client's nasogastric
tz
tube. Which of the following actions should the nurse take?
sh
Sp
A. Position the head of the client's bed at 15 degrees®
ne
B. Mix the medications together in a medication cup
la
C. Pour the medications into the enteral formula container
tz
sh
D. Flush the tube with water before and after instilling each medication
Sp
Correct Ans - D. Flush the tube with water before and after instilling each
ne
medication
la
tz
sh
A nurse enters a client's room and finds the client sitting on the floor and
Sp
leaning against the side of the bed. The client states she slipped while
ne
getting out of bed. Which of the following actions should the nurse take first?
la
A. Complete an incident report
tz
sh
B. Check the client for injuries
Sp
C. Make sure the client has skid-free footwear
ne
D. Remind the client to ask for help with getting out of bed Correct Ans -
la
B. Check the client for injuries
tz
sh
Sp
ne
la
sh
Sp
la
Sp
