ATI Pre-Assessment Exam
Question 1
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings as a manifestation of a stage 3 pressure ulcer?
- A) Exposed bone
- B) Blood-filled blisters
- C) Partial-thickness skin loss
- D) Necrotic subcutaneous tissue
A nurse is caring for a client who has a tracheostomy. Select the 3 findings that require immediate follow-up.
- A) Blood pressure on day 2
- B) Oxygen saturation on day 2
- C) Tracheal secretions
- D) Breath sounds day 1
- E) Respiratory rate day 2
Question 3
A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client’s lunch tray?
- A) Lemon sherbet
- B) Plain yogurt
- C) Cranberry juice
- D) Carrot juice
Question 4
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications?
- A) Acetaminophen
- B) Celecoxib
- C) Cyclobenzaprine
- D) Ibuprofen
Question 5
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving?
- A) Bargaining
- B) Denial
- C) Depression
- D) Anger
Question 6
A nurse is caring for a client who states, “I have got to get out of this hospital! They have found my address and are coming for my family.” The nurse responds, “Don’t worry, no one will harm your family.” Which of the following types of communication breakdown does this response represent?
- A) Providing a passive response
- B) Showing disapproval
- C) Offering false reassurance
- D) Offering sympathy
Question 7
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
- A) An upper respiratory infection
- B) Pulmonary edema
- C) Atelectasis
- D) Delayed gastric emptying
Question 8
A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?
- A) Instill the drops into the inner canthus
- B) Approach the client’s eye from below it
- C) Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac
- D) Ask the client to look down when instilling the solution
Question 9
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?
- A) “I am thinking of getting a second opinion.”
- B) “I am hoping this will limit my discomfort.”
- C) “This treatment should help me live a little longer.”
- D) “This is not working and I plan to stop treatment.”
.”
Question 10
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client’s edema?
- A) 4+
- B) 3+
- C) 2+
- D) 1+
Question 11
A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?
- A) The client had an appendectomy 6 months ago.
- B) The client has bipolar disorder.
- C) The client is a male.
- D) The client is 71 years old.
Question 12
A nurse is caring for a client who is receiving continuous enteral feedings. The client has chills, appears flushed, and has a temperature of 39°C (102.2°F). The nurse should suspect that the client is at risk for developing which of the following conditions?
- A) Dehydration
- B) Infection
- C) Tube displacement
- D) Fluid overload
Question 13
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?
- A) Droplet
- B) Contact
- C) Airborne
- D) Standard
Question 14
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A) Disconnect the tube from the wall suction.
- B) Perform hand hygiene.
- C) Provide mouth care to the client.
- D) Verify the provider’s prescription to discontinue the tube.
Question 15
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
- A) “Information about a client can be disclosed to family members at any time.”
- B) “HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form.”
- C) “A client’s address would be an example of personally identifiable information.”
- D) “HIPAA is a federal law, not a state law.”
Question 16
A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions:
- Elevate the extremity
- Stop the infusion
- Apply warm or cold compresses
- Remove the IV catheter
- Apply a sterile dressing
Correct Order:
Question 17
A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
- A) The client has a capillary refill of less than 2 seconds.
- B) The client has full range of motion in her wrist.
- C) The client is attempting to remove the restraint.
- D) The client’s hand is cool and pale.
.
Question 18
A nurse is interviewing a female client who is Hispanic. The client’s partner answers the questions and states, “She speaks only a little English.” Which of the following actions should the nurse take?
- A) Arrange to complete the assessment with only the client and a translator present.
- B) Ask the client’s partner to translate questions and answers for the client.
- C) Ask a male student nurse to translate for the client.
- D) Use an internet website ending in .com to translate for the client.
Question 19
A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene?
- A) Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm.
- B) Withdrawing the needle and massaging the site gently.
- C) Stretching the skin tightly before injection.
- D) Visualizing the tip of the needle under the skin.
.
Question 20
A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?
- A) When determining if the client is eating a well-balanced diet.
- B) When asking the client about his receptiveness to the transfer.
- C) When asking the client how he completes his ADLs.
- D) When asking if the client took his medications this morning.
Question 21
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
- A) Explain oral hygiene to a client receiving chemotherapy
- B) Bathe a client who had an amputation 2 days ago
- C) Feed a client who had a stroke 3 months ago
- D) Assist a client to ambulate using a gait belt
- E) Review a low-sodium diet for a client who has hypertension
Question 22
A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?
- A) Transdermal patch
- B) Sublingual
- C) Suspended-release
- D) Topical ointment
Question 23
A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?
- A) Place the client in a lateral position
- B) Provide an adaptive feeding device for the client
- C) Initiate a liquid diet for the client
- D) Arrange the food groups clockwise on the client’s plate
Question 24
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?
- A) Bradypnea
- B) Somnolence
- C) Pallor
- D) Tachycardia
Question 25
A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?
- A) 25 mg/dL
- B) 13 mg/dL
- C) 10 mg/dL
- D) 18 mg/dL
Question 26
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?
- A) Apply a vest restraint on the client
- B) Place the client in bed with the two side rails raised
- C) Place a seat alarm in the client’s chair
- D) Administer lorazepam to the client
Question 27
A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?
- A) Inject 10 units of air into the regular insulin vial
- B) Inject 20 units of air into the NPH insulin vial
- C) Withdraw 10 units of insulin from the regular insulin vial
- D) Replace the needle for withdrawal with a safety needle
Question 28
A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?
- A) Emphasize four important points at each session
- B) Use a passive voice to explain the information
- C) Refer to the client in the third person during the session
- D) Have short teaching sessions
Question 29
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
- A) Suction two to three times with a 60-second pause between passes
- B) Perform chest physiotherapy prior to suctioning
- C) Lubricate the suction catheter tip with sterile saline
- D) Hyperventilate the client on 100% oxygen prior to suctioning
Question 30
A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of their day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?
- A) Increased insulin production
- B) Decreased RBC production
- C) Decreased sodium excretion
- D) Increased calcium excretion
Answer:
Question 1
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings as a manifestation of a stage 3 pressure ulcer?
- A) Exposed bone
- B) Blood-filled blisters
- C) Partial-thickness skin loss
- D) Necrotic subcutaneous tissue
Correct Answer: D) Necrotic subcutaneous tissue
A nurse is caring for a client who has a tracheostomy. Select the 3 findings that require immediate follow-up.
- A) Blood pressure on day 2
- B) Oxygen saturation on day 2
- C) Tracheal secretions
- D) Breath sounds day 1
- E) Respiratory rate day 2
Correct Answers:
- B) Oxygen saturation on day 2
- C) Tracheal secretions
- E) Respiratory rate day 2
Question 3
A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client’s lunch tray?
- A) Lemon sherbet
- B) Plain yogurt
- C) Cranberry juice
- D) Carrot juice
Correct Answer: C) Cranberry juice