ATI Fundamentals Proctored Exam |
Questions and Answers with Rationales |
1. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of
the following actions should the nurse take first?
A. Give the client a glass of water
-incorrect: The nurse should provide ...
ati fundamentals proctored exam | questions and answers with rationales | 1 a nurse is preparing to insert an ng tube for a client who has a bowel obstruction which of the following actions should t
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ATI Fundamentals Proctored Exam |
Questions and Answers with Rationales |
LATEST 2022
1. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of
the following actions should the nurse take first?
A. Give the client a glass of water
-incorrect: The nurse should provide a glass of water to facilitate swallowing during tube
insertion of the NG tube. However, there is another action the nurse should take first.
B. Assist the client into a sitting position
-incorrect: The nurse should assist the client into a sitting position to insert the NG tube more
easily and allow gravity to help facilitate the passage of the tube. However, there is another
action the nurse should take first.
C. Explain the procedure to the client
-The nurse should apply the least invasive priority-setting framework when caring for this client,
which assigns priority to nursing interventions that are least invasive to the client, as long as
those interventions do not jeopardize client safety. The nurse should take interventions that are
not invasive to the client before interventions that are invasive. This reduces the number of
organisms introduced into the body, decreasing the number of facility-acquired infections.
Informing the client about the procedure reduces fear and assists in gaining the client’s
cooperation, which is important for NG tube insertion and is the priority nursing intervention.
D. Measure the length of tubing to be inserted
-incorrect: The nurse should measure the length of the tubing to be inserted to ensure proper tube
placement. However, there is another action the nurse should take first.
2. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client?
A. Sweeping the floor
-incorrect: sweeping the floor is moderate-intensity activity
B. Shoveling snow
-incorrect: Shoveling snow is a high-intensity activity
C. Cleaning windows
-incorrect: Cleaning windows is a moderate-intensity activity
D. Washing dishes
-Washing dishes requires a low level of activity and is appropriate for this client.
3. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has
ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the
nurse should document for this client? (round to nearest whole number)
,-1560
4. A nurse is performing a physical examination of a client. The nurse should use percussion to
evaluate which of the following parts of the client’s body?
A. Heart
-incorrect: The nurse uses inspection, palpation, and auscultation to evaluate the heart.
B. Lungs
-Percussion creates a vibration that helps the examiner determine the density of the underlying
tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound
over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The
nurse also uses auscultation and palpation when evaluating the lungs.
C. Thyroid gland
-incorrect: The nurse uses inspection and palpation to evaluate the thyroid gland.
D. Skin
-incorrect: The nurse uses inspection and palpation to evaluate the skin.
5. A nurse is supervising a newly licensed nurse who is administering a controlled substance.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
A. Placing an unused portion of the medication in a sharps box
-incorrect: The nurse should not dispose of an unused portion of a controlled substance in the
sharps container because this action does not maintain safe control of the narcotic.
B. Asking another nurse to observe the disposal of an unused portion of the medication
-The nurse should ask another nurse to witness the disposal of a controlled substance to maintain
safe control of the narcotic.
C. Counting the inventory of the available narcotic after administering the medication
-incorrect: The nurse should count the inventory of the controlled substance before removing a
dosage to maintain safe control of the narcotic.
D. Ensuring that another nurse signs the control inventory form after disposal of an unused
portion of medication
-incorrect: Two nurses should sign the control inventory form after the disposal of a portion of a
narcotic to maintain safe control.
6. A nurse is caring for a client who has acute renal failure. Which of the following assessments
provides the most accurate measure of the client’s fluid status?
A. Daily weight
-According to the evidence-based priority-setting framework, daily weight provides important
information about the client’s fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss
of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status
measurement.
B. Blood Pressure
-incorrect: While blood pressure can indicate a client’s fluid gain or losses, it is not the most
accurate method of measuring fluid changes.
C. Specific gravity
,-incorrect: Specific gravity reflects the kidney’s ability to concentrate urine. While specific
gravity reflects client’s fluid gains or losses, it is not the most accurate method used to measure
fluid changes.
D. Intake and Output
-incorrect: Intake and output reflect a client’s fluid status. However, this is not the most accurate
method to measure fluid changes.
7. A nurse in a long-term care facility is admitting a client who is incontinent and smells
strongly of urine. His partner, who has been caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
A. “A lot of clients who are cared for at home have the same problem”
-incorrect: This automatic response implies that caregivers in the home are not able to keep
client’s odor-free. It is a judgmental statement that is not therapeutic.
B. “Don’t worry about it. He will get a bath, and that will take care of the odor.”
-incorrect: Telling the partner not to worry blocks communication by devaluing her feelings and
her concern about the odor.
C. “It must be difficult to care for someone who is confined to bed.”
-This response addresses the feelings of the partner by reflecting her feelings, which facilitates
therapeutic communication because it is nonjudgmental and encourages the partner to express
her feelings.
D. “When was the last time that he had a bath?”
-incorrect: This response implies that the odor of urine has developed because she has not bathed
her husband for some time, which is judgmental and nontherapeutic.
8. A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the client’s
skin turgor?
A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to
become pink.
-incorrect: This technique assesses capillary refill.
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs
back.
-The nurse should use this technique to assess skin turgor. If the client has good turgor and is
properly hydrated, the skin will immediately return to normal; in dehydration, the skin will
remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the
forearm.
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression.
-incorrect: This technique determines the extent of a client’s pitting edema.
D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.
-incorrect: This technique determines a client’s body fat percentage.
9. A nurse discovers that a client received the wrong medication. Which of the following actions
should the nurse take first?
A. Complete a medication error report
, -incorrect: The nurse should follow the facility’s protocol for documenting the incident;
however, this is not the first action the nurse should take.
B. Notify the prescribing provider
-incorrect: The nurse should follow the facility’s protocol for reporting a medication error, which
usually involves notifying the prescribing provider; however, this is not the first action the nurse
should take.
C. Assess the client
-The greatest risk to the client’s safety is adverse effects from either receiving the wrong
medication or not receiving the prescribed medication. The nurse should assess the client first for
any possible adverse effects. This assessment also serves as a baseline for further monitoring for
adverse effects.
D. Notify the charge nurse
-The nurse should follow the facility’s protocol for reporting a medication error, which usually
involves notifying the charge nurse; however, this is not the first action the nurse should take.
10. A nurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for stool
collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a tongue
depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory
after labeling the specimen properly to prevent contamination with microorganisms and keep the
specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the client
label on the container and the bag for easy identification. This will also prevent contamination
with microorganisms.
11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the
following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several
minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the
tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
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