ATI RN Fundamentals A Exam Latest 2022

40.          A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

a.            Assist the client with a partial bed bath.

Assisting a client with a bed bath poses minimal risk to the client and is within the AP’s range of function.

b.            Measure the client’s BP after the nurse administers an antihypertensive medication.

Measuring a client’s BP poses minimal risk to the client and is within AP’s range of function.

c.             Test the client’s swallowing ability by providing thickened liquids.

Assessing the client’s swallowing ability places the client at risk for aspiration and is not within the AP’s range of function. Nurses perform tasks that require assessment.

d.            Use a communication board to ask what the client wants for lunch.

Using a communication board poses minimal risk to the client and is within the AP’s range of function. 

e.            Irrigate the client’s indwelling urinary catheter.

Irrigating the client’s indwelling urinary catheter is an invasive procedure and is not within the AP’s range of function.

 

41.          A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

a.            “I can place an extension cord across my living room to plug in mu television.”

Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping.

b.            “I will hire someone to trim the trees that hangs low over the stairs of my front porch.”

Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

c.             “I will place my alarm clock on my bedroom dresser across the room.”

Frequently used items like an alarm clock, or disposable tissues should be placed within reach, such as on the client’s night stand. This helps to prevent the client from needing to get up and potentially falling in the night.

d.            “I will replace the old throw rug in my kitchen with a new one.”

Using throw rugs increases the client’s risk for fall because they create a tripping and slipping hazard for the client.

 

42.          A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

a.            Numbness of extremities

This is manifestation of hyperkalemia. 

b.            Bradycardia

Tachycardia is a manifestation of hyponatremia along with hypovolemia.

c.             Positive Chvostek’s sign

A positive Chvostek’s sign is a manifestation of hypomagnesemia and hypocalcemia.

d.            Abdominal cramping 

This client who has hyponatremia, which is low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

 

43.          A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

a.            Insert the catheter at a 45o angle.

Generally, the nurse should insert the catheter at 10o to 30o angle. However, for an older adult client, an angle of 10o to 15o is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue.

b.            Place the client’s arm in a dependent position.

The nurse should place the client’s arm in a dependent position because the veins will dilate due to gravity.

c.             Shave excess hair from the insertion site.

The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection

d.            Initiate IV therapy in the veins of the hands.

The nurse should avoid using the fragile veins of an older adult’s hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client’s hand can interfere with the client’s performance of ADLs and can diminish an older adult sense of independence and ability.

 

44.          A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

a.            Advocacy ensures client’s safety, health, and rights.

Advocacy is a key component of professional nurses’ code of ethics. As a client advocate, the nurse ensures clients’ safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

b.            Advocacy ensures that nurses are able to explain their own actions.

Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer.

c.             Advocacy ensures that nurses follow through on their promises to clients.

Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients.

d.            Advocacy ensures fairness in client care delivery and use of resources.

Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care.

 

45.          A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning?

a.            During the admission process.

Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client’s needs and plan for care both during and after the client’s time in the facility.

b.            As soon as the client’s condition is stable.

Although it is appropriate to defer client teaching until the client is stable and receptive to learning the initiation of discharge planning does not depend on the client’s physiological stability.

c.             During the initial team conference.

Team conference facilitate discharge planning, but they are not essential for initiating the planning process.

d.            After consulting with the client’s family.

The nurse should only consult with the client’s family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs.

 

46.          A nurse is talking with the partner of a client who has dementia. The client’s partner expresses finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following type of role-performance stress?

a.            Role ambiguity

This occurs when people are unclear about the expectations of their role in a given situation.

b.            Sick role

This refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver.

c.             Role overload

The partner’s expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

d.            Role conflict

This develops when a person must assume multiple roles that have opposing expectations.

 

47.          A nurse is teaching a client and his family how to care for the client’s tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

a.            Remove the outer cannula cautiously for routine cleaning.

The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning.

b.            Use tracheostomy covers when outdoors.

Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne particles.

c.             Use sterile technique when performing tracheostomy care at home.

In the home environment, medical asepsis with clean technique is appropriate.

d.            Cleanse irritated skin with full-strength hydrogen peroxide.

Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation.

 

48.          A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. which of the following actions should the nurse take next?

a.            Document the provider’s statement in the medical record.

The nurse should document the provider’s directions in the medical record for later reference; however, another action is the nurse’s priority.

b.            Complete an incident report.

The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse’s priority.

c.             Consult the facility’s risk manager.

The nurse should discuss the situation with the facility’s risk management department to help determine the need for preventive actions; however, another action is the nurse’s priority.

d.            Notify the nursing manager.

The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chai of command to ensure that the client receives the necessary care. 

 

49.          A nurse is administering 1 L of 0.9 sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

a.            Increase in hematocrit

FVD cause an increase in hematocrit level due to depletion of ECF. With correction of the imbalance, the hematocrit level should decrease.

b.            Increase in respiratory rate

FVD causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range.

c.             Decrease in heart rate

FVD causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. 

d.            Decrease in capillary refill time

FVD slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.

 

50.          A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

a.            Contact

Contact precautions are a requirement for client who have infections that spread via direct contact or from environmental contact. Examples: VRE and herpes simplex infections.

b.            Droplet

Droplet precautions are a requirement for a clients who have infections that spread via droplet nuclei larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis the nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

c.             Airborne

Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei smaller than 5 microns in diameter, including varicella, tuberculosis, and measles

d.            Protective

Clients who have a compromised immune system, such as those who have received allogenic stem cell transplant, require a protective environment. This precaution keep them from acquiring infections from others.

 

51.          A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

a.            Examine personal values about the issue.

Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

b.            Tell the parents that this is necessary procedure.

The nurse should provide parents with information about the procedure. However, telling the parents that this is a necessary procedure disregard the parents religious beliefs and their right to refuse treatments.

c.             Inform the parents that the staff does not require their consent.

Parents must give consent for a child to receive a blood transfusion.

d.            Contact a spiritual support person to explain the importance of the procedure.

The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients and families spiritual needs, not their physiological needs.

 

52.          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?

a.            Critical pathway

This is and interprofessional approach to planning all phases of client care.

b.            Situation, background, assessment, and recommendation (SBAR)

SBAR is a communication tool nurses use to relate a client’s status during a change-of-shift report.

c.             Transfer report

The nurse should use a transfer report when the client is moving from one health care area to another. 

d.            Medication administration record (MAR) 

The nurse should use the MAR to document medication administration.

 

53.          A nurse in a provider’s office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client’s patellar reflex?

 

One with the knee.

54.          A nurse is assessing an older adult client’s risk for fall. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select all that apply.)

a.            Lacrimal apparatus

If clients have impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. 

b.            Pupil clarity

Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. 

c.             Appearance of bulbar conjunctivae

The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client’s safety.

d.            Visual fields

The nurse should use a finger to test the client’s peripheral vison by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall.

e.            Visual acuity

The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Client who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

 

55.          A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse’s priority?

a.            Request that a respiratory therapist discuss the technique for incentive spirometry with the client.

The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take.

b.            Determine the reasons why the client is refusing to use the incentive spirometer.

The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

c.             Document the client’s refusal to participate in health restorative activities.

If other interventions to promote the client’s use of the incentive spirometer are unsuccessful, the nurse must document the client’s refusal; however, this is not the priority action for the nurse to take.

d.            Administer a pain medication to the client.

Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take. 

 

56.          A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

a.            Bladder distention

Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles.

b.            Decreased blood pressure

A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moved from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness.

c.             Calf swelling

Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

d.            Diminished bowel sounds

A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication of immobility.

 

57.          A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

a.            Discuss the risk factors for colon cancer.

The client might perceive this as challenging or argumentative and react offensively. Instead, the nurse should listen to the client’s concerns and should avoid challenging him.

b.            Focus teaching on what the client will need to do in the future to manage his illness.

During the anger stage of the client’s psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future.

c.             Provide the client with written information about the phases of loss and grief.

Unless the client requests reading materials about loss, this is not an optimal time to provide them. At this stage, the client needs to express his feelings without any expectations for learning.

d.            Reassure the client that this is an expected response to grief.

During the anger stage of the client’s psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

 

58.          A nurse is preparing to administer an injection of an opioid to a client. The nurse draws out 1 mL of the medication from a 2 mL vial, which of the following actions should the nurse take?

a.            Ask another nurse to observe the medication wastage.

A second nurse must witness the disposal of any portion of a dose of a controlled substance.

b.            Notify the pharmacy when wasting the medication.

Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance.

c.             Lock the remaining medication in the controlled substances cabinet.

The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substance Act.

d.            Dispose of the vial with the remaining medication in a sharps container.

The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substance Act.

 

59.          A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

a.            Position the client with the head of the bed elevated to 30o prior to insertion of the NG tube. 

The client should be sitting in high-Fowler’s position with the head of the bed elevated to 90o to reduce the risk of aspiration.

b.            Remove the NG tube if the client begins to gag or choke.

The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. 

c.             Apply suction to the NG tube prior to insertion.

The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client.

d.            Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

 

60.          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?

a.            Protective environment

Clients who have a compromised immune system require a protective environment.

b.            Airborne precautions

Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles.

c.             Droplet precautions

Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis.

d.            Contact precautions

Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.