Download 2025 A.T.I Fundamentals Proctored Nursing Exam Explained: Question Count, Test Structure and more Exams Nursing in PDF only on Docsity!
2025 ATI Fundamentals Proctored Nursing
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Explained: Question Count, Test Structure, and
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Question 1: 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.) A. Image showing 4 mL in a medication cup. B. Image showing 6 mL in a medication cup. C. Image showing 8 mL in a medication cup. D. Image showing 10 mL in a medication cup. Rationale: The correct answer is C. To calculate the correct dosage, use the following formula: Available DoseDesired Dose×Volume=Amount to Administer 12.5 mg20 mg×5 mL=12.5100 mL=8 mL Therefore, the nurse should administer 8 mL of the diphenhydramine syrup. Question 2: 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." Rationale: The correct answer is D. Placing the ring in a locked storage unit provides the most secure option for the client's valuable. Placing it in a drawer (A) or pinning it to the gown (B) does not guarantee its safety. While holding onto it (C) is an option, it places responsibility on the nurse and is not a standard procedure for securing patient valuables. Question 3: 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. Rationale: The correct answer is D. Restraints should only be used as a last resort when a client poses an imminent threat to their own safety or the safety of others. Pacing (A) is not necessarily a reason for restraints. Restraints should not be used routinely for fall prevention (B). Family requests (C) alone are not sufficient justification for restraints; there must be a clinical indication of danger. Question 4: 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. Rationale: The correct answer is B. In this situation, the nurse manager is acting as a client educator by providing guidance and evaluating the newly licensed nurse's competency in performing the procedure safely and correctly. While client safety is a component of client advocacy (D), the primary role here is teaching and ensuring competency. The nurse manager is not directly managing the client's overall care (A) or providing direct client care (C) in this observational role. Question 5:
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. Rationale: The correct answer is D. An ethical dilemma occurs when there is a conflict between two or more ethical principles or values, and there is no clear right or wrong answer. In this case, the ethical principles of veracity (truth-telling) and beneficence (acting in the client's best interest, as perceived by the family) are in conflict. The surgeon's refusal to take responsibility (A) is an issue of accountability and potential legal ramifications. The client's insurance coverage (B) is a healthcare access issue. The client's refusal to work with the therapist (C) is a matter of client autonomy, but not necessarily an ethical dilemma for the nurse unless it significantly impacts the client's well-being and the nurse's duty to provide care. Question 8: A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the client 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." Rationale: The correct answer is D. Examining the axillary lymph nodes using circular motions with the fingertips is a crucial part of a thorough breast self-examination. Performing the exam the week after the period starts (A) is generally recommended due to decreased breast tenderness. While different patterns (B) can be used on each breast to ensure all areas are covered, it's not a specific indicator of understanding. The pads of the fingers, not the palm (C), should be used to apply pressure during the examination. 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 - - correct ans- - 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 - - correct ans- - 1. perform hand hygiene
- 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 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 - - correct ans- - 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 b. Pull the clients pinna up & back
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" d. "Don't you have access to condoms?" - - correct ans- - c A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? a. Move items in the room away from the client b. Turn the client onto their side c. Help the client lie on the floor d. Loosen the client's clothing - - correct ans- - c A nurse is testing a client for conduction deafness by performing Weber's test. Which of the following actions should the nurse take when performing this test? a. Move a vibrating tuning form in front of the client's ear canals one after the other b. Place the base of a vibrating tuning fork on the client's mastoid process c. Place the base of a vibrating tuning fork on the top of the client's head d. Count how many seconds a client can hear a tuning fork after it has been struck - - correct ans-
- c A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement? a. Warfarin b. Albuterol c. Levothyroxine
d. Atorvastatin - - correct ans- - a A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take? a. Discuss alternative treatments with the client b. Explain to the client the risks involved with not having the procedure c. Express approval of the client's decision to not have the procedure d. Document the client's decision in the medical record - - correct ans- - d A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. " I will have my partner help me change position every 4 hours" b. " I will remove my antiembolic stockings while I am in bed" c." I will hold my breath when rising from a sitting position" d." I will perform ankle and knee exercises every hour." - - correct ans- - d A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Oatmeal b. Applesauce c. Scrambled eggs d. Plain Yogurt - - correct ans- - d A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history?
A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, " I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? a. " Let's talk more about your dad's condition." b. "The social worker will help you answer those questions." c. " Try to help your dad enjoy this time as much as he can." d. " I think that you should discuss this with the hospice nurse." - - correct ans- - a A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity? a. The client's room number b. The client's admitting diagnosis c. The name of the client's next of kind. d. The client's telephone number - - correct ans- - d A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team. a. Social worker b. Occupational therapist c. Registered Dietician d. Primary care provider - - correct ans- - a A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching? a. " I will place the client in a Private room." b. " I will remove my gown before my gloves after providing client care."
c. " I will wear an N95 respirator mask when caring for the client." d. " I will tell the client's visitors to wear a mask when they are within 3 feet of the client." - - correct ans-
- a A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? a. Cover the blood pressure cuff with a stockinette. b. Wear powdered gloves when providing care to the client. c. Apply adhesive tape when securing an IV insertion site. d. Use plastic syringes for medication administration. - - correct ans- - a A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, " I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? a. Describe the surgery to the client. b. Notify the Provider. c. Complete an incident report d. Provide brochures about the procedure. - - correct ans- - b A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. " SQ" for subcutaneous b. "SS" for sliding scale c. "BRP" for bathroom privileges d. "OJ" for orange juice - - correct ans- - c
d. "Let me provide you with the client's medical record number for identification." - - correct ans-
- a During change of shift report, a nurse discovers she overlooked a prescription for a type and crossmatch of a client who is to have surgery the next day. Which of the following actions should the nurse take first? a. Inform the provider of the delay in obtaining the type and cross-match. b. Obtain the client's type and cross-match. c. Prepare an incident report for risk management. d. Document the incident in the client's medical record. - - correct ans- - a A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag? a. An emesis basin filled with blood from severe coughing b. A bedpan containing diarrhea from a client who was receiving antibiotics c. A disposable tissue containing expectorated sputum d. A calibrated toilet insert filled with urine. - - correct ans- - a A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula? a. Check for gastric residual volume b. Encourage the client to breathe deeply and cough. c. Flush the tube with sterile 0.9% sodium chloride irrigation. d. Encourage the client to take sips of water. - - correct ans- - a A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly?
a. The client has a dry mouth b. The client is coughing c. The client has active bowel sounds d. The client is hiccuping - - correct ans- - b A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Assess the client for a gag reflex b. Measure the pH of the gastric c. Place the end of the NG tube in the water to observe for bubbling d. Asculatate 2.5 cm above the umbilicus while injecting 15 ml of water - - correct ans- - b A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse? a. Would you like to get you a back massage? b. Why do you think pain med is not going to help you? c. You may take any herbal remedies you bring from home d. I'm sure it will work if you just give it a chance - - correct ans- - a a nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? a. Bradycardia b. Postural hypotension c. Distended neck vein d. Dependent edema - - correct ans- - b
A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions should the nurse include in the teaching? a. clean the hearing aid by soaking it in warm water b. Turn the hearing aid off and the volume down before insertion c. Replace the battery if the hearing aid emits a whistling sound d. Leave the battery in place when the hearing aid is not in use - - correct ans- - b A nurse is teaching a client about the care and use of hearing aids. Which of the following should the nurse take? a. Observe the client's eyes for the six cardinal position of gaze b. Verify the client's ability to read letters on a snellen eye chart c. Check the client's pupil reaction when focusing on distant and nearby objects d. Test the client's eyes for reactions to light response - - correct ans- - c A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching? a. holding the object close to the body b. holding the object away from the body - - correct ans- - a A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take? a. Change the clients position every 4 hours b. Apply petroleum base ointment in the red area c. Assess the red area for blanching d. Use friction when cleansing the client's skin - - correct ans- - c
A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care. a. request a prescription for an indwelling urinary cath - - correct ans- - a A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should be included in the teaching? (select all that apply) a. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation b. Remove from the artificial eye by retracting the upper eyelid c. Apply pressure just below artificial eye to break the suction d. Clear the artificial eye with hydrogen peroxide before storing d. Retract the upper and lower lids to reinsert the artificial eye - - correct ans- - c, d, e A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? a. Determine areas of resonance across the abdomen using a systematic approach b. Expose the client's abdomen to look for changes in appearance c. Perform abdominal palpation by pressing gently with the finger pads d. Use the diaphragm of the stethoscope to listen for bowel sounds - - correct ans- - b A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority? a. Determine the client's reading ability b. Review the use of an artificial larynx c. With the client schedule a support session d. For the client explain the techniques of esophageal speech - - correct ans- - d
A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse? a. "lets discuss your concerns about your father," or anything along those lines that is therapeutic. - - correct ans- - a a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes b. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly c. I should soak my feet in warm water daily to soften corns and calluses d. I should use an over the counter liquid medication to remove corns - - correct ans- - a A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Tie the restraints to the side rail b. Secure restraints with a square knot c. Remove one restraint at a time d. Remove the restraints every 3 hours - - correct ans- - c A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply a. Use an N95 respirator while providing client care b. wear a gown and gloves when providing client care c. assign the client to a private room with positive air flow d. wash hands with soap and water after contact with the client e. Ensure the client does not receive fresh fruits - - correct ans- - b, c, d
A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? a. Schedule the client as the first surgical procedure of the day b. Cleanse the stoppers with primidone iodine for withdrawing medication c. Remove the stop stocks from iv tubing d.Ensure the gloves in the surgical suite are powdered gloves - - correct ans- - a A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following action should the nurse take? a. direct verbal discharge instruction to the interpreter - - correct ans- - a A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn? a. The client's belief that his needs will be met through education b. The nurse explaining the need for education to the client c. The client seeking family approval by agreeing to a teaching plan d. The nurse's empathy about the client having to self-inject - - correct ans- - aa A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take? a. Heat the formula to 105 degrees Fahrenheit b. Flush the tubing with 10 ml of water every 2 hours c. Change the tubing every 72 hours d. Aspirate residual volume every 4 hours (Every 4-8 hours is correct) - - correct ans- - d
