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ATI RN Fundamentals Online Practice Assessment 2019
Version 2– Nursing Foundations Practice Questions and
Rationales Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take first? A. Provide the client with nonskid footwear. B. Complete a fall-risk assessment for the client. C. Keep the client’s bed in the lowest position. D. Place a fall-risk identifier on the client’s door. Ans: B Rationale: The nurse should first use the nursing process to assess the client’s specific needs and risks. Completing a fall-risk assessment provides the baseline data needed to implement targeted interventions. Once the risk level is determined, the nurse can then provide nonskid footwear and keep the bed in the lowest position as part of the safety plan. Placing an identifier on the door is a secondary action to alert other staff members of the risk. Assessment is always the initial step before implementing safety protocols in a clinical setting. This ensures that the care provided is individualized and addresses the unique vulnerabilities of the patient. Following the assessment, the nurse should document the findings to maintain clear communication within the healthcare team. 2. A nurse is preparing to administer an enema to a client. Which of the following positions should the nurse place the client in? A. Left-lateral Sims’ position B. High-Fowler’s position
C. Supine position D. Dorsal recumbent position Ans: A Rationale: The left-lateral Sims’ position is the most appropriate for enema administration because it allows the solution to flow downward into the sigmoid colon and rectum by gravity. In this position, the client lies on their left side with the right knee flexed. High-Fowler’s position is used for respiratory distress or eating and would not facilitate fluid entry into the colon. The supine position does not provide the necessary anatomical alignment for comfortable rectal insertion. The dorsal recumbent position is typically used for vaginal examinations or catheterization in females. Proper positioning ensures the procedure is effective and minimizes discomfort for the client. The nurse should always explain the rationale for the position to the client to increase cooperation and ease anxiety. Safety and privacy must also be maintained throughout the procedure.
3. A nurse is preparing to use a fire extinguisher to put out a small fire in a client’s room. Which of the following actions should the nurse take first? A. Aim the nozzle at the base of the fire. B. Squeeze the handle of the extinguisher. C. Pull the pin on the fire extinguisher. D. Sweep the extinguisher from side to side. Ans: C Rationale: The nurse should follow the PASS acronym when using a fire extinguisher, starting with pulling the pin. Pulling the pin unlocks the operating lever and allows the nurse to discharge the extinguisher contents. After pulling the pin, the nurse should aim the nozzle at the base of the fire to
5. A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following actions should the nurse take? A. Use an alcohol-based hand rub. B. Rub hands together for at least 5 seconds. C. Wash hands with soap and water. D. Dry hands starting from the elbows to the fingers. Ans: C Rationale: Soap and water must be used for hand hygiene when caring for clients with C. difficile because the spores are resistant to alcohol-based rubs. Friction and running water are necessary to physically remove the spores from the skin’s surface. Alcohol-based rubs are effective against many pathogens but do not kill spore-forming bacteria. The nurse should rub their hands together with soap for at least 15 to 20 seconds to ensure adequate cleansing. Drying should occur from the cleanest area (fingers) to the least clean area (wrists or forearms). This protocol is a fundamental part of contact precautions and infection control. Adhering to these guidelines prevents the transmission of healthcare- associated infections to other vulnerable patients. The nurse plays a critical role in breaking the chain of infection within the hospital environment. 6. A nurse is assessing a client’s radial pulse and finds it to be irregular. Which of the following actions should the nurse take next? A. Check the radial pulse on the opposite wrist. B. Document the finding and notify the provider. C. Reassess the radial pulse for 30 seconds. D. Assess the apical pulse for 1 full minute.
Ans: D Rationale: When an irregular radial pulse is detected, the nurse must assess the apical pulse for a full 60 seconds to obtain an accurate heart rate. This allows the nurse to identify the specific rhythm and any pulse deficits that might exist. Assessing for a full minute is necessary because shorter intervals might miss irregular beats. Notifying the provider is appropriate, but only after a complete and accurate assessment has been performed. Checking the opposite wrist may confirm the irregularity but does not provide the most accurate heart rate measurement. The apical pulse is the most reliable non-invasive method for evaluating cardiac function. This step ensures that clinical decisions are based on the most comprehensive data available. Proper technique in vital sign assessment is essential for recognizing early signs of patient deterioration.
7. A nurse is teaching a client about how to use a cane. Which of the following instructions should the nurse include? A. Hold the cane on the weaker side of the body. B. Move the stronger leg forward first when walking. C. Keep two points of support on the floor at all times. D. Advance the cane 30 to 45 cm (12 to 18 in) with each step. Ans: C Rationale: To maintain stability and balance, the client should keep two points of support (either both feet or one foot and the cane) on the floor at all times. The cane should be held on the stronger side of the body to provide better support and weight distribution. When walking, the client should move the cane forward first, followed by the weaker leg, and then the stronger leg. Advancing the cane too far forward (30-45 cm) can cause the client to lose their balance and fall. Usually, the cane should be moved forward about 15 to 25 cm (6 to 10 inches). Proper cane height should be at the level of the greater trochanter to
C. Place the client in a supine position. D. Use a firm toothbrush to clean the client’s teeth. Ans: A Rationale: The nurse should turn the client’s head to the side to prevent aspiration of fluids during oral care. This position allows secretions to drain out of the mouth by gravity rather than pooling in the back of the throat. The client should never be supine because this significantly increases the risk of choking and pneumonia. Minimal fluid should be used, and a suction catheter should be available to remove any excess liquid or secretions. A soft toothbrush or foam swab is preferred to prevent trauma to the sensitive mucous membranes. Frequent oral care is necessary to prevent infection and maintain the integrity of the oral mucosa. It also improves the client’s overall comfort and hygiene while they are unable to perform these tasks themselves. The nurse must prioritize airway protection throughout the entire hygiene procedure.
10. A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include? A. Use wool blankets on the bed while using oxygen. B. Apply petroleum jelly to the nares if they become dry. C. Keep the oxygen tank at least 10 feet away from open flames. D. Wear cotton clothing while using the oxygen equipment. Ans: D Rationale: Cotton clothing is recommended because it does not generate static electricity, which can be a fire hazard in an oxygen-rich environment. Wool and synthetic fabrics should be avoided as they can easily produce sparks. Petroleum-based products like Vaseline are flammable and should not be used on
the face or in the nares; water-based lubricants are safer. Oxygen tanks should be kept at least 5 to 10 feet away from heat sources or open flames, such as gas stoves or candles. The nurse must emphasize that smoking is strictly prohibited near oxygen use due to the high risk of combustion. Patients should also be taught to secure tanks properly to prevent them from falling and becoming projectiles. Education on home safety is a vital part of the discharge process for respiratory patients. Ensuring the patient understands these risks helps prevent devastating accidents at home.
11. A nurse is evaluating a client’s understanding of a low-sodium diet. Which of the following food choices by the client indicates an understanding of the teaching? A. Canned vegetable soup B. Smoked ham sandwich C. Fresh orange slices D. Pretzels with sea salt Ans: C Rationale: Fresh fruits like orange slices are naturally low in sodium and are excellent choices for a client on a restricted diet. Processed foods, such as canned soups and smoked meats, contain very high levels of sodium added for preservation and flavor. Pretzels, even those with sea salt, are highly processed snacks that should be avoided. Clients should be taught to read nutrition labels carefully to identify hidden sources of sodium. Reducing sodium intake is a key intervention for managing conditions like hypertension and heart failure. The nurse should encourage the use of herbs and spices as alternatives to salt for flavoring food. Successful dietary modification requires the client to recognize which common foods contribute most to their daily sodium load. Consistent reinforcement of these choices promotes better long-term health outcomes.
Ans: B Rationale: To begin a 24-hour urine collection, the nurse must have the client void and discard that first specimen to ensure the bladder is empty at the start time. All subsequent urine for the next 24 hours must be collected in the designated container. If any urine is accidentally discarded during the 24-hour period, the entire test must be restarted to ensure accuracy. The container is typically kept on ice or refrigerated to prevent the breakdown of components and bacterial growth. The client should be instructed not to put toilet paper in the collection container. Clear labeling with the start and end times is essential for the laboratory to process the results correctly. This test is often used to evaluate kidney function or levels of specific hormones and proteins. Accurate collection is critical for a valid diagnostic outcome.
14. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take to maintain surgical asepsis? A. Reach over the sterile field to pick up supplies. B. Keep sterile gloved hands above the waist level. C. Place the sterile drape so that it hangs over the edge of the table. D. Open the top flap of the sterile package toward the body. Ans: B Rationale: Maintaining sterile hands above the waist and within the field of vision is a fundamental principle of surgical asepsis. Anything below the waist is considered contaminated because it cannot be constantly monitored for sterility. Reaching over a sterile field can introduce microorganisms from the nurse’s clothing or skin, so it must be avoided. The edges of a sterile field (usually a 1-inch border) are considered contaminated, so supplies should be placed in the center. Sterile packages should be opened by moving the first flap away from the body to prevent reaching over the field later. If the sterile drape
hangs over the edge, the portion below the table level is no longer sterile. These meticulous steps are necessary to prevent surgical site infections. Consistency in aseptic technique is a hallmark of professional nursing practice.
15. A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take? A. Measure the blood pressure while the client is sitting only. B. Check the pulse rate only after the client has been standing for 5 minutes. C. Wait 1 to 3 minutes after the client changes positions before measuring BP. D. Perform the assessment immediately after the client finishes a meal. Ans: C Rationale: To assess for orthostatic hypotension, the nurse should measure blood pressure and heart rate after the client has been in each position (supine, sitting, and standing) for 1 to 3 minutes. This delay allows the cardiovascular system to adjust to the change in posture. A positive finding includes a drop in systolic blood pressure of at least 20 mm Hg or a drop in diastolic pressure of at least 10 mm Hg. An increase in heart rate of 20 beats per minute or more can also indicate orthostatic changes. The assessment should not be done immediately after a meal, as digestion can affect blood flow and results. Safety is a priority, so the nurse must stay close to the client in case they become dizzy or faint. Documenting the findings clearly for each position is necessary for the provider to make a diagnosis. Teaching the client to rise slowly can help manage symptoms of this condition. 16. A nurse is using the SBAR communication tool to report a change in a client’s condition to a provider. Which of the following statements should the nurse include in the ‘A’ (Assessment) portion of the report? A. ‘The client was admitted with a diagnosis of pneumonia.’ B. ‘The client is experiencing increased shortness of breath and fine crackles.’
injury or nerve damage and should be avoided; a gait belt is much safer. The client should never place their arms around the nurse’s neck, as this can lead to neck or back injury for the nurse. Instead, the client should push off the bed with their hands to assist with the move. The nurse should use their legs, not their back, to provide power during the transfer. Proper body mechanics protect both the nurse and the client from musculoskeletal injuries. Safety during mobility is a fundamental aspect of nursing care.
18. A nurse is preparing to administer a medication to a client. Which of the following is the most reliable method for identifying the client? A. Ask the client’s roommate to verify their identity. B. Check the name on the sign above the client’s bed. C. Compare the client’s name and birthdate on the ID band with the MAR. D. Ask the client, ‘Are you Mr. Jones?’ Ans: C Rationale: The most reliable way to identify a client is to use at least two unique identifiers, such as their full name and date of birth, and verify them against the Medication Administration Record (MAR) and the client’s ID band. Asking a roommate or checking a bed sign is unreliable and prone to error, as signs can be outdated and roommates may be mistaken. Asking the client ‘Are you Mr. Jones?’ is a closed-ended question that a confused or hard-of-hearing client might agree to incorrectly. The nurse should ask the client to state their name and birthdate whenever possible. This process is one of the ‘rights’ of medication administration and is essential for preventing medication errors. Standardizing identification procedures across a facility improves patient safety and quality of care. The nurse must perform this check every single time a medication is given.
19. A nurse is performing a physical assessment on a client’s abdomen. In which order should the nurse perform the following techniques? A. Inspection, Palpation, Percussion, Auscultation B. Auscultation, Inspection, Palpation, Percussion C. Inspection, Auscultation, Percussion, Palpation D. Percussion, Auscultation, Inspection, Palpation Ans: C Rationale: For an abdominal assessment, the sequence is inspection, auscultation, percussion, and palpation. Inspection is always done first to look for visible abnormalities like distention or masses. Auscultation must follow inspection because percussion and palpation can stimulate bowel activity and change the bowel sounds heard. Percussion is then used to assess for gas or fluid, and palpation is the final step to check for tenderness or organs. This specific order ensures that the nurse obtains the most accurate information about the client’s gastrointestinal status. In other body systems, palpation usually precedes auscultation, making the abdomen a unique case. The nurse should ensure the client is comfortable and has an empty bladder before beginning. Systematic assessment is vital for early detection of potential complications. 20. A nurse is teaching a client who has a new diagnosis of diabetes about foot care. Which of the following instructions should the nurse include? A. Soak your feet in warm water for 20 minutes daily. B. Wear well-fitting, closed-toe shoes at all times. C. Apply lotion between the toes to prevent dryness. D. Use a heating pad on your feet if they feel cold at night.
be harmful to the client. The nurse should also monitor for signs of intolerance, such as abdominal distention or nausea. Ensuring the tube is properly positioned before each use is a critical safety check. These protocols are essential for providing safe nutritional support to compromised patients.
22. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items can the nurse provide to the client? A. Vanilla pudding B. Orange juice with pulp C. Chicken broth D. Fruit yogurt Ans: C Rationale: Chicken broth is a clear liquid because it is transparent and liquid at room temperature. A clear liquid diet includes items like water, tea, coffee (without cream), fat-free broth, carbonated beverages, and gelatin. Vanilla pudding, fruit yogurt, and orange juice with pulp are part of a full liquid diet, not a clear liquid diet. Clear liquids are often prescribed before certain diagnostic tests or after surgery to minimize strain on the digestive system. They provide hydration and some electrolytes but are nutritionally inadequate for long-term use. The nurse should verify the client’s preferences while adhering to the diet’s restrictions. Careful monitoring of the client’s tolerance as they transition to more solid foods is important. Providing a variety of allowed liquids can help improve client satisfaction during this period. 23. A nurse is assessing a client’s wound and notes a thick, yellow-green drainage. The nurse should document this as which of the following types of exudate? A. Serous B. Purulent
C. Serosanguineous D. Sanguineous Ans: B Rationale: Purulent drainage is thick and can be yellow, green, or brown, often indicating the presence of an infection. Serous drainage is clear and watery, typically seen in the early stages of healing. Sanguineous drainage is bright red and indicates active bleeding from the wound. Serosanguineous drainage is a pale, pink, watery mixture of clear and red fluid. Correct identification and documentation of wound drainage are essential for monitoring healing and detecting complications early. The nurse should also note the odor, amount, and consistency of the exudate. If purulent drainage is present, a wound culture may be necessary to identify the infecting organism. Comprehensive wound assessment includes checking the wound bed, edges, and surrounding skin. This information guides the healthcare team in choosing the most appropriate wound care interventions.
24. A nurse is providing teaching to a client about using an incentive spirometer. Which of the following instructions should the nurse include? A. Exhale forcefully into the mouthpiece. B. Use the device once every 4 hours while awake. C. Inhale slowly and deeply through the mouthpiece. D. Hold your breath for at least 10 seconds after each use. Ans: C Rationale: The proper technique for using an incentive spirometer involves taking a slow, deep breath in through the mouthpiece to expand the lungs. This action helps prevent atelectasis and promotes gas exchange, especially in postoperative clients. Exhaling into the device is incorrect; the client should
26. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? A. Use the non-dominant hand to separate the labia. B. Lubricate the catheter tip 2.5 to 5 cm (1 to 2 in). C. Clean the labia using a back-to-front motion. D. Insert the catheter 15 to 20 cm (6 to 8 in) into the urethra. Ans: A Rationale: The nurse should use their non-dominant hand to separate the labia, which then becomes contaminated and must remain in place until the catheter is inserted. Cleaning should always be done from front to back to prevent the introduction of bacteria from the anal area into the urethra. For a female client, the catheter tip should be lubricated about 2.5 to 5 cm (1 to 2 inches). The catheter is typically inserted 5 to 7.5 cm (2 to 3 inches) until urine flows, then advanced another 2 to 5 cm (1 to 2 inches). Surgical asepsis must be strictly maintained throughout the entire procedure to prevent catheter-associated urinary tract infections (CAUTIs). After the balloon is inflated, the nurse should gently tug on the catheter to ensure it is secure. Proper drainage bag placement below the level of the bladder is also essential. Educating the client on what to expect can help reduce anxiety during the procedure. 27. A nurse is caring for a client who has a hearing impairment. Which of the following communication strategies should the nurse use? A. Face the client directly when speaking. B. Exaggerate lip movements to help the client read lips. C. Shout loudly while standing close to the client’s ear.
D. Use high-pitched tones to improve clarity. Ans: A Rationale: Facing the client directly allows them to see the nurse’s facial expressions and lip movements, which aids in understanding. Shouting is often counterproductive because it can distort the sound and seem aggressive. Exaggerating lip movements can actually make it harder for a person to lip-read. The nurse should speak in a normal, clear tone and avoid high-pitched sounds, as many people with hearing loss have difficulty hearing higher frequencies. It is also helpful to minimize background noise and ensure the room is well-lit. Written communication or sign language interpreters should be used if necessary. Rephrasing rather than simply repeating the same words can help if the client does not understand the first time. Respectful communication is essential for building a therapeutic relationship with the client.
28. A nurse is preparing to measure a client’s temperature using a tympanic thermometer. Which of the following actions should the nurse take? A. Pull the pinna down and back for an adult client. B. Pull the pinna up and back for an adult client. C. Wait 30 minutes if the client has just finished a cold drink. D. Gently push the thermometer probe deep into the ear canal. Ans: B Rationale: For an adult client, the nurse should pull the pinna up and back to straighten the ear canal and allow the infrared sensor to reach the tympanic membrane. For children under 3 years old, the pinna should be pulled down and back. Waiting after a cold drink is necessary for oral temperatures, but it does not affect a tympanic reading. The probe should be placed snugly into the outer ear canal, but it should never be pushed deep into the canal to avoid injury. Tympanic thermometers are useful because they provide a quick and non-invasive core temperature measurement. The nurse should ensure the probe
