ATI Proctored Fundamentals Exam

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of

the following findings should the nurse expect?

- Albumin Level of 3g/dL

A nurse is caring for a client who reports pain. When documenting the quality of the

client's pain on an initial pain assessment, the nurse should record which of the following

client statements?

- "The pain is like a dull ache in my stomach."

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A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the

following statements should the nurse identify as an indication that the client

understands the teaching?

- "When descending stair, I will first shift my weight to my right leg."

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125

mL/hr. When the nurse performs the initial assessment, he notes that the client has

received only 80 mL over the last 2 hrs. Which of the following actions should the nurse

take first?

- Check the IV tubing for obstruction

A nurse is caring for a client who asks about the purpose of advance directives. Which of

the following statements should the nurse make?

- "They indicate the form of treatment a client is willing to accept in the event

of a serious illness." 

A nurse is caring for four clients. Which of the following tasks should the nurse delegate

to an assistive personnel?

- Arrange the lunch tray for a client with a hip fracture

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A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock.

When the nurse notifies the surgeon, he directs her to continue to measure the client's

vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the

following actions should the nurse take next?

- Notify the nursing manager

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the

following findings at the IV site should the nurse identify as infiltration?

- Skin Blanching

A nurse is preparing a change-of-shift report. Which of the following tools or documents

should the nurse use to communicate continuity of care?

- Situation, Background, Assessment, and Recommendation (SBAR)

A nurse is admitting a client who has an abdominal wound with a large amount of

purulent drainage. Which of the following types of transmission precautions should the

nurse initiate?

- Contact Precautions

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed

with a nasal cannula delivering oxygen. Which of the following interventions should the

nurse take first?

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- Assist the client to an upright position.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings

should the nurse report to the provider?

- Potassium 5.4 meq/L 

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To

prevent self-injury, which of the following actions should the nurse take when lifting this

object?

- Stand close to the cabinet when lifting it.

A nurse is giving discharge instructions to a client who will require oxygen therapy at

home. Which of the following statements should the nurse identify as an indication that

the client understands how to manage this therapy at home?

- "I'll check the wires and cables on my TV to make sure they are in good

working order."

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV

catheter. After which of the following observations should the nurse remove the IV

catheter?

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- Swelling and coolness are observed at the IV site

A nurse in a provider's office is obtaining the health and medication history of a client

who has a respiratory infection. The client tells the nurse that she is not aware of any

allergies, but that she did develop a rash the last time she was taking an antibiotic. Which

of the following information should the nurse give to the client?

- "We need to document the exact medication you were taking because you

might be allergic to it."

A nurse on a medical-surgical unit is caring for a client who has a new prescription for

wrist restraints. Which of the following actions should the nurse take?

- Pad the client's wrist before applying the restraints.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The

client's partner wants the client to have the blood transfusion. Which of the following

actions should the nurse take?

- Withhold the blood transfusion. 

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