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ATI FUNDAMENTALS RETAKE EXAM
LATEST REAL QUESTIONS AND
CORRECT ANSWERS GRADE A
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting
- CORRECT ANSWER d. have family members wear a gown and gloves when visiting A nurse is caring for a family experiencing a crisis. What approach should the nurse use when working with a family using an open structure for coping with crisis? - CORRECT ANSWER Convening a family meeting. What should you do before administering any medications? - CORRECT ANSWER Obtain a complete medication and allergy history. What does diphenhydramine treat in relation to allergic reactions?
- CORRECT ANSWER Mild rashes and hives
What should you do after hand-washing with ostomy skin care? - CORRECT ANSWER Apply gloves & inspect the stoma, use mild soap and water to cleanse, then dry it gently and completely. What are the steps to take when administering a large-volume enema? - CORRECT ANSWER 1. Position the client on the left side with right leg flexed forward. Put on gloves. Lubricate rectal tube or nozzle. (Also, warm to enema solution).
- Slowly insert rectal tube (3 to 4 inches for an adult). Raise bag above anus, 18 inches (if client reports abd cramping, lower the enema fluid container). Ask the client to retain the solution for prescribed amount of time, or until client is no longer able to retain it.
- Discard bag. Assist the client to the appropriate position to defecate. Document results and the client's tolerance of the procedure. What should the nurse do to help prevent plantar flexion? - CORRECT ANSWER Encourage active or provide passive ROM two or three times/day. Instruct clients to perform ROM while bathing, eating, grooming, and dressing. What should be done for a client to promote a proper sleep-wake cycle? - CORRECT ANSWER Cluster care. ` Who is a fracture pan used for? - CORRECT ANSWER Supine client and clients in body casts or leg casts. What should the nurse do for clients using a fracture pain? - CORRECT ANSWER Raise the head of the bed to 30 degrees. If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan.
What should the nurse do if she were to find a surgical wound separated with viscera protruding? - CORRECT ANSWER Cover the area with saline-soaked sterile dressing and position the client supine with his hips & knees bent. What is the expected reference range for ALT? - CORRECT ANSWER 4 to 36 units/L. Elevation occurs with hepatitis or cirrhosis. What are indications for ALT? - CORRECT ANSWER Suspected liver, pancreatic, or billiary tract disorder. When do you use surgical asepsis for suctioning? - CORRECT ANSWER Surgical asepsis should be used for nasotracheal suctioning, but medical asepsis for the mouth. How long should the nurse suction for? - CORRECT ANSWER No longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Limit total suctioning to 5 minutes. What position will promote draining of both lobes of the lungs in general? - CORRECT ANSWER High Fowler's What position will promote draining of apical segments of both lobes? - CORRECT ANSWER Sitting on the side of the bed What position will promote draining of both lower lobes of the lungs, anterior segments? - CORRECT ANSWER Supine in Trendelenburg What position will promote draining of both lower lobes, posterior
segments? - CORRECT ANSWER Prone in Trendelenburg What should there nurse do when caring for a client who has a C. Diff infection? - CORRECT ANSWER Implement contact precautions including gloves & a gown. Ensure the client has a private room & maintain a clean environment. Implement infection control measures including but not limited to hand washing, performing wound care measures, and encourage adequate rest and nutrition. A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. Clean contaminated surfaces in the client's room with a phenol solution.The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. Have family members wear a gown and gloves when visiting.Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves. A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds
and sterile technique. This task is outside the range of function of an AP. Demonstrating the use of an incentive spirometer to a clientClient education requires advanced nursing knowledge and is outside the range of function of an AP. Confirming that a client's pain has decreased after receiving an analgesicEvaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed" - CORRECT ANSWER c. "client found lying on the floor" An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation. "Client climbed over the side rails."Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings. "Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. "Client was trying to get out of bed."Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse's findings.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound. - CORRECT ANSWER c. cleanse the wound from the center outward The nurse should wear clean gloves to remove the old dressing. Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation solution to body temperature. Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation. A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment - CORRECT ANSWER a. droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5
could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea - CORRECT ANSWER c. 8 oz of ice chips 2 cups of soup. The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid. 1 quart of water. The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid. 8 oz of ice chips. The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 6 oz of tea. The nurse should understand that 6 oz of tea is equal to 180 mL of fluid. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene - CORRECT ANSWER a,b,e
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? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene - CORRECT ANSWER b. withhold the blood transfusion A direct donation still requires a blood transfusion and does not respect the client's wishes. Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment. Request a consultation with the ethics committee.A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee. Ask the client's family to intervene.Clients who are competent have the right to consent to or refuse treatment. 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? a. "when descending the stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "As I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits" - CORRECT ANSWER a. "when descending the stairs, I will first shift my weight to my right leg"
Urine specific gravity is 1.035.A urine specific gravity of 1. indicates that the urine is concentrated; however, it is not an indication for irrigation. Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Urine is positive for ketones.Urine that is positive for ketones is a sign of diabetes mellitus with poor glucose control; however, it is not an indication for irrigation. A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day - CORRECT ANSWER a. erythema on pressure points Erythema on pressure pointsErythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. Lower-extremity pulse strength of 2+A lower-extremity pulse strength of 2+ is an expected finding. Fluid intake of 3,000 mL per day. Clients should receive 2,000 to 3,000 mL of fluid per day. One bowel movement every other dayBowel movements less frequent than three times per week can indicate constipation and the need for intervention. However, a bowel movement every other day does not require intervention.
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol - CORRECT ANSWER b. tell the client to keep the head of the bed elevated at least 30 degrees The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro- organisms that could contaminate the formula; however, there is another action that is the priority. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission.
For a 24-hr urine collection, the client should collect urine that is free of feces. "I have a specimen in the bathroom from about 30 minutes ago."For a 24-hr urine collection, the client should place any urine in the container immediately and keep it on ice or in a refrigerator. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. "I drink a lot, so I will fill up the bottle and complete the test quickly."For a 24-hr urine collection, there is no specified amount. The collection takes place over a 24-hr period regardless of the total volume of urine collected. A nurse is planning care for a client who has tuburculosis. The nurse should use which of the following pieces of PPE when providing care for the client? a. gown b. N95 respirator c. Shoe covers d. Surgical cap - CORRECT ANSWER b. N95 respirator The nurse should wear a gown when providing care for a client who requires contact precautions to prevent the transmission of bacteria. N95 respirator.The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria. Shoe coversThe nurse should wear shoe covers when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection.
Surgical capThe nurse should wear a surgical cap when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection. A nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? (SATA)
- Place the client in a room with negative-pressure
- Wear gloves when assisting the client with oral care
- Limit each visitor to 2-hr increments
- Wear a surgical mask when providing client care
- Use antimicrobial sanitizer for hand hygiene - CORRECT ANSWER - Place the client in a room with negative-pressure
- Wear gloves when assisting the client with oral care
- Use antimicrobial sanitizer for hand hygiene Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negativepressure airflow to meet the requirements of airborne precautions.Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.Limit each visitor to 2hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outsid
Neck vein distension is a clinical manifestation of fluid volume excess. Urine specific gravity 1.010T ypically, a client's urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. The expected reference range for urine specific gravity is 1.005 to 1.030. Rapid heart rate. Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Blood pressure 144/82 mm HgHypotension is an expected finding for a client who has fluid volume deficit. A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia(PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0- 10 d. increase the basal rate and shorten the lock-out inter - CORRECT ANSWER a. instruct the family to refrain from pushing the button for the client while she is asleep The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.
Inform the client that because she is on PCA, vital signs will be taken every 8 hr.The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10.The nurse should instruct the client to activate the PCA pump when she needs it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump. Increase the basal rate and shorten the lock-out interval time if t A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week - CORRECT ANSWER b. a client who smokes one pack of cigarettes each day A client who is 52 years oldClients who are 60 years of age or older are at an increased risk for hypertension. A client who smokes one pack of cigarettes each day. A client who smokes one pack of cigarettes each day is at an increased risk for hypertension. A client who walks for 30 min every dayRegular physical exercise lowers the risk for developing hypertension. A client who drinks one glass of wine three times per weekAlthough heavy alcohol consumption can increase the risk for hypertension, drinking one glass of wine three times per week is not considered heavy consumption.
