ATI FUNDAMENTALS PROCTORED ACTUAL EXAM (540
QUESTIONS & ANSWERS WITH RATIONALE) TEST BANK
LATEST UPDATE 100% VERIfiED ANSWERS| GRADED A+
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which
of the following images indicates the correct number of mL the nurse should administer?
(round answer to the nearest whole number.)
DOSAGE CALCULATION - ANSWER: 8ml
A nurse is admitting a client who is malnourished. The client states, "My wedding ring is
loose and I'm worried I will lose it if it falls off."Which of the following is an appropriate
response by the nurse?
a. " I will place it in your drawer so it won't get lost."
b. I can pin it to your hospital gown so you won't lose it."
c. "I will hold onto it until a family member can take it home."
d. I can put it in a locked storage unit for you - ANSWER: d
A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In
which of the following clinical situations should the nurse apply restraints?
a. If the client is pacing in the hallway
b. As a part of a fall prevention program
c. At the request of the client's family
d. When the client poses a threat to self - ANSWER: d
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization on a client. In which of the following roles is the nurse
manager functioning?
a. Case manager
b. Client educator
c. Client care provider
d. Client advocate - ANSWER: d
Page | 1
,A charge nurse in a long-term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
a. "Delirium does not affect a client's perception of her environment."
b. "Delirium does not affect a client's sleep cycle."
c. "Delirium has an abrupt onset."
d. "Delirium has a slow progression." - ANSWER: c
A nurse is speaking with a client who has recently received a diagnosis of a chronic illness.
The client states, " The doctor must be wrong. I can't be that sick". The nurse should inform
the client that their reaction is an example of which of the following expected responses to
grief?
a. Acceptance
b. Denial
c. Anger
d. Depression - ANSWER: b
A Nurse on a medical-surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
a. A surgeon who removed the wrong kidney during a surgical procedure refuses to take
responsibility for her actions
b. A client who has Crohn's disease reports that his prescription drug plan will not pay for his
medications.
c. A client who has a new colostomy refuses to take instructions from the ostomy therapist
because she "doesn't like him."
d. the family of a client who has a terminal illness asks the provider not to tell the client the
diagnosis - ANSWER: d
A nurse is teaching a client about performing breast self-examinations. Which of the
following statements by the clients indicates an understanding of the teaching?
a. "I should perform my self-exam the week that my period starts"
b. "I should make different patterns on each breast when I do my self-exam."
c. "I should use the palm of my hand to apply pressure to each breast."
d. "I should make circular motions with my fingertips under my arms." - ANSWER: d
Page | 2
,A nurse is preparing to transfer a client who is partially weight bearing from the bed to the
chair. Which of the following actions should the nurse take?
a. Keep his knees straight when moving the client
b. Position the chair next to the bed as a 90 degree angle
c. Stand with his feet together when lifting the client
d. Have the client bear weight on her stronger leg - ANSWER: d
A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication. ( Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)
- Select the injection port of the IV tubing closest to the client.
- Cleanse the injection port with an antiseptic swab.
- Aspirate for blood return.
- Inject the medication.
- perform hand hygiene - ANSWER: 1. perform hand hygiene
2. select the injection port of the IV tubing closest to the client
3. cleanse the injection port with an antiseptic swab
4. aspirate for blood return
5. inject the medication
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin.
Which of the following statements but the client indicates an understanding of the teaching
a. I should wait 3 minutes after mixing the insulin to inject it
b. I should draw up the NPH insulin before regular insulin
c. I should inject air into the vial of regular insulin first
d. I should roll the vial of NPH insulin between my hands before drawing it up -
ANSWER: d
A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
a. Slide the probe across the clients forehead
Page | 3
, b. Pull the clients pinna up & back
c. Hold the client's hair aside while performing the procedure
d. Document the client's temperature with "AX" next to the value
e. Move the probe in a circular motion - ANSWER: a, c
A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the
following actions should the nurse take to help dilate the vein?
a. Stroke the skin near the vein in an upward position
b. Dangle the client's arm over the edge of the bed
c. Apply a cool compress to the vein for 10 min
d. Instruct the client to flex their arm with the hand open - ANSWER: b
A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions
should the nurse plan to take?
a. Apply intermittent suction during catheter insertion
b. Suction the client's airway for 20 seconds with each pass
c. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning
d. decrease suction pressure to 150 mm Hg if the O2 sat levels drop during suctioning -
ANSWER: a
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of
the following finding is the nurse's priority?
a. Last bowel movement was 3 days ago
b. Reports pain of 8 on a scale of 0 to 10
c. Distended bladder
d. Respiratory rate 7/min - ANSWER: d
A nurse is caring for a client who has been treated multiple times for STIs. Which of the
following responses should the nurse take?
a. "You must have too many sexual partners"
b. "Why do you keep letting this happen?"
c. "Let's explore why this might be re-occuring"
Page | 4
QUESTIONS & ANSWERS WITH RATIONALE) TEST BANK
LATEST UPDATE 100% VERIfiED ANSWERS| GRADED A+
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which
of the following images indicates the correct number of mL the nurse should administer?
(round answer to the nearest whole number.)
DOSAGE CALCULATION - ANSWER: 8ml
A nurse is admitting a client who is malnourished. The client states, "My wedding ring is
loose and I'm worried I will lose it if it falls off."Which of the following is an appropriate
response by the nurse?
a. " I will place it in your drawer so it won't get lost."
b. I can pin it to your hospital gown so you won't lose it."
c. "I will hold onto it until a family member can take it home."
d. I can put it in a locked storage unit for you - ANSWER: d
A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In
which of the following clinical situations should the nurse apply restraints?
a. If the client is pacing in the hallway
b. As a part of a fall prevention program
c. At the request of the client's family
d. When the client poses a threat to self - ANSWER: d
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse
perform a straight catheterization on a client. In which of the following roles is the nurse
manager functioning?
a. Case manager
b. Client educator
c. Client care provider
d. Client advocate - ANSWER: d
Page | 1
,A charge nurse in a long-term care facility is preparing an educational program about
delirium for newly hired nurses. Which of the following statements should the nurse plan to
include?
a. "Delirium does not affect a client's perception of her environment."
b. "Delirium does not affect a client's sleep cycle."
c. "Delirium has an abrupt onset."
d. "Delirium has a slow progression." - ANSWER: c
A nurse is speaking with a client who has recently received a diagnosis of a chronic illness.
The client states, " The doctor must be wrong. I can't be that sick". The nurse should inform
the client that their reaction is an example of which of the following expected responses to
grief?
a. Acceptance
b. Denial
c. Anger
d. Depression - ANSWER: b
A Nurse on a medical-surgical unit is providing care for four clients. The nurse should
identify which of the following situations as an ethical dilemma?
a. A surgeon who removed the wrong kidney during a surgical procedure refuses to take
responsibility for her actions
b. A client who has Crohn's disease reports that his prescription drug plan will not pay for his
medications.
c. A client who has a new colostomy refuses to take instructions from the ostomy therapist
because she "doesn't like him."
d. the family of a client who has a terminal illness asks the provider not to tell the client the
diagnosis - ANSWER: d
A nurse is teaching a client about performing breast self-examinations. Which of the
following statements by the clients indicates an understanding of the teaching?
a. "I should perform my self-exam the week that my period starts"
b. "I should make different patterns on each breast when I do my self-exam."
c. "I should use the palm of my hand to apply pressure to each breast."
d. "I should make circular motions with my fingertips under my arms." - ANSWER: d
Page | 2
,A nurse is preparing to transfer a client who is partially weight bearing from the bed to the
chair. Which of the following actions should the nurse take?
a. Keep his knees straight when moving the client
b. Position the chair next to the bed as a 90 degree angle
c. Stand with his feet together when lifting the client
d. Have the client bear weight on her stronger leg - ANSWER: d
A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a
prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify
the sequence of steps the nurse should follow to administer the medication. ( Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)
- Select the injection port of the IV tubing closest to the client.
- Cleanse the injection port with an antiseptic swab.
- Aspirate for blood return.
- Inject the medication.
- perform hand hygiene - ANSWER: 1. perform hand hygiene
2. select the injection port of the IV tubing closest to the client
3. cleanse the injection port with an antiseptic swab
4. aspirate for blood return
5. inject the medication
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin.
Which of the following statements but the client indicates an understanding of the teaching
a. I should wait 3 minutes after mixing the insulin to inject it
b. I should draw up the NPH insulin before regular insulin
c. I should inject air into the vial of regular insulin first
d. I should roll the vial of NPH insulin between my hands before drawing it up -
ANSWER: d
A nurse is assessing the body temperature of an adult client using a temporal artery
thermometer. Which of the following actions should the nurse take? (Select all that apply)
a. Slide the probe across the clients forehead
Page | 3
, b. Pull the clients pinna up & back
c. Hold the client's hair aside while performing the procedure
d. Document the client's temperature with "AX" next to the value
e. Move the probe in a circular motion - ANSWER: a, c
A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the
following actions should the nurse take to help dilate the vein?
a. Stroke the skin near the vein in an upward position
b. Dangle the client's arm over the edge of the bed
c. Apply a cool compress to the vein for 10 min
d. Instruct the client to flex their arm with the hand open - ANSWER: b
A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions
should the nurse plan to take?
a. Apply intermittent suction during catheter insertion
b. Suction the client's airway for 20 seconds with each pass
c. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning
d. decrease suction pressure to 150 mm Hg if the O2 sat levels drop during suctioning -
ANSWER: a
A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of
the following finding is the nurse's priority?
a. Last bowel movement was 3 days ago
b. Reports pain of 8 on a scale of 0 to 10
c. Distended bladder
d. Respiratory rate 7/min - ANSWER: d
A nurse is caring for a client who has been treated multiple times for STIs. Which of the
following responses should the nurse take?
a. "You must have too many sexual partners"
b. "Why do you keep letting this happen?"
c. "Let's explore why this might be re-occuring"
Page | 4
