ATI PN Fundamentals Exam Form B | Questions and Answers with Rationales | Latest 2020 / 2021
1. A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)
A. -Place a towel unde...
ATI PN Fundamentals Exam Form B
| Questions and Answers with
Rationales | Latest 1.A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)
A.-Place a towel under the client's head with an emesis basin under their chin.
B.-Assess the client's gag reflex.
C.-Cleanse the client's mouth using a toothbrush.
D.-Separate the client's upper and lower teeth with an oral airway device.
E.-Position the client on their side with their head turned to the side.
ANS: B,E,A,D,C Rationale: 1- Assess the client's gag reflex. (The nurse should first assess the client's gag reflex to determine risk for aspiration)
2- Position the client on their side with their head turned to the side. (Turning the client on their side allows secretions to drain from the mouth).
3- -Place a towel under the client's head with an emesis basin under their chin.(Using a towel and emesis basin helps protect bed linens). 4- Separate the client's upper and lower teeth with an oral airway device. (An oral airway device allows safe access to the client's mouth).
5- Cleanse the client's mouth using a toothbrush (Finally, the client's mouth can be cleansed with a toothbrush or swabs).
2.A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? A.Measure the client's gastric residual before each feeding.
B.Change the bag and tubing every 24 hours.
C.Document intake and output.
D.Flush the tubing with 30 mL of water after each feeding.
Rationale: When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take).
3.A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?
A.Sit beside the client.
B.Speak slowly and loudly.
C.Dim the lights in the client's room.
D.Choose a private room for the interview. Rationale: The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying).
4.A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which the following entities?
A.An insurance agency offering a life insurance policy.
B.A family member who requests the client's diagnosis.
C.A physical therapist who is involved in the client's care.
D. An employer completing a pre-employment screening. Rationale: According to HIPPA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care).
5.A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include?
A."This dressing keeps the wound bed dry."
B."This dressing allows the wound bed to breathe."
C."This dressing requires a secondary dressing."
D.This dressing requires paper tape to secure."
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