ATI RN Fundamentals A Exam Latest 2022

ATI RN Fundamentals A

1.            A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

a.            A lesion with uniform pigmentation

Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy.

b.            New appearance of petechiae

Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy.

c.             A mole with asymmetrical appearance

An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part

d.            The presence of a papule

Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy.

 

2.            A nurse is assessing a client who reports pain following physical therapy. Which of the following questions should the nurse as when assessing the quality of the client’s pain?

a.            “Is your pain constant or intermittent?”

Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain.

b.            “What would you rate your pain on a scale of 0 to 10?”

Asking the client to rate the pain using the pain scale determines the intensity of the pain.

c.             “Does the pain radiate?”

Asking the client whether the pain radiates determines the pain’s location.

d.            “Is your pain sharp or dull?”

Asking the client whether the pain is sharp or dull, crushing, throbbing, aching, burning, electric- like, or shooting helps determine the quality of the pain.

 

3.            A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

a.            Verify the client’s name on their identification bracelet with the medication administration record.

The nurse should verify the client’s name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation.

b.            Call the pharmacy to determine whether the client’s medications are available.

The nurse should call the pharmacy if the client’s medications are not available to administer at the appropriate time; however this action is not a part of performing medication reconciliation

c.             Compare the client’s home medications with the provider’s prescriptions.

The nurse should compare the client’s home medications with the provider’s prescriptions when performing medication reconciliation.

d.            Place the client’s home medication bottles in a secure location.

The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation.

 

4.            A nurse is auscultating the anterior chest of a client who was admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.)

a.            Crackles

Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways.

b.            Rhonchi

Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions.

c.             Friction rub

Friction rub is a scratching sound that persists throughout the respiratory cycle. 

d.            Normal breath sounds

These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.

 

5.            A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

a.            Administer the medication with the needle at 45o angle.

The nurse should insert the needle at 45o to 90omangle for a subcutaneous injection.

b.            Administer the medication into the client’s nondominant arm.

The nurse should administer enoxaparin into the abdomen, at least 5cm (2 inches) from the umbilicus.

c.             Pull the client’s skin laterally or downward prior to administration.

The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection.

d.            Massage the injection site after the administration.

The nurse should not massage the injection following the injection of an anticoagulant due to the risk for bruising.

 

6.            A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary catheter. Which of the following actions should the nurse take?

a.            Place the client in a side-lying position.

b.            Instill 15 mL of irrigation fluid into the catheter with each flush.

c.             Subtract the amount of irrigant used from the client’s urine output.

d.            Perform the irrigation using a 20-mL syringe.

 

7.            A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use?

a.            Alginate

Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage.

b.            Gauze

Moistened gauze promotes healing in stage 4 or unstageable injuries by causing debridement and allowing granulation of the wound bed.

c.             Transparent

Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and sharing.

d.            Hydrocolloid

Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 

 

8.            A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

a.            Insert the needle at a 15o angle

The nurse should instruct the client to insert the needle at a 45o to 90o angle to administer into the subcutaneous tissue.

b.            Aspirate for blood return prior to administration

The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. 

c.             Administer the medication into the abdomen

The nurse should instruct the client to administer the medication into the abdomen at least 5.08cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

d.            Massage the site following the injection

The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising. 

 

9.            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?

a.            Pad the client’s wrist before applying restraints.

The use of restraints without padding can abrade the client’s skin, resulting in client injury.

b.            Evaluate the client’s circulation every 8hr after application.

The nurse should evaluate the client’s circulation, range of motion, vital signs, and overall status every 15 min after the initial application of restraints.

c.             Remove the restraints every 4hr to evaluate the client’s status.

The nurse should remove the restraints at least every 2hr to reposition the client and assess needs for hygiene and toileting. 

d.            Secure the restraint ties to the bed’s side rails.

The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.

 

10.          A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client?

a.            Make sure the client’s room has at least six air exchanges per hour.

A protective environment requires at least 12 air exchanges per hour. 

b.            Make sure the client wears mask when outside her room if there is construction in the area.

An allogenic stem cell transplant compromises the client’s immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

c.             Place the client in a private room that provides negative-pressure airflow.

The nurse should place the client in a private room that provides positive-pressure airflow.

d.            Wear an N95 respirator when giving the client direct care. 

The nurse should wear an N95 respirator mask when caring for a client who require airborne precautions, not a protective environment.

 

11.          A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

a.            Use a bed-exit alarm system

The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client’s condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

b.            Raise four side rails while the client is in bed

Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury.

c.             Apply soft wrist restraint

Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or interventions to maintain client safety should be attempted for clients who have dementia.

d.            Dim the lights in the client’s room

Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk of injury.

 

12.          A nurse is preparing to administer 0.9% sodium chloride 750mL IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

 

107 mL/hr

 

13.          A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

a.            Biofeedback

Biofeedback is complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique.

b.            Aloe

Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy.

c.             Feverfew

Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy. 

d.            Acupuncture

The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin’s surface could increase the risk of further infection.

 

14.          A nurse is lifting a bedside cabinet to mover 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? 

a.            Bend at the waist.

The nurse should bend the knees when lifting the cabinet.

b.            Keep the feet close together.

The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet.

c.             Use his back muscles for lifting.

The nurse should use the arm and leg muscles when lifting the cabinet because they are generally stronger than back muscles. 

d.            Stand close to the cabinet when lifting it.

This action keeps the cabinet close to the nurse’s center of gravity and decreases back strain from horizontal reaching. 

 

15.          A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make?

a.            “You would have so much more time to spend with your family.”

This response is nontherapeutic because the nurse is minimizing the client’s feelings and making assumptions about the client’s relationships.

b.            “You should consider getting a part-time job or doing volunteer work.”

This response is nontherapeutic because the nurse is minimizing the client’s feelings and offering personal advice.

c.             “Let’s talk about how the change in your job status will affect you.”

This response is therapeutic because the nurse is encouraging the clients to verbalize feelings about the life transition of retirement.

d.            “Why wouldn’t you want to retire and relax?”

This response is nontherapeutic because the nurse is asking a “why” question, which can provoke a defensive response form the client.

 

16.          A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, “Every time you change my bandage, it hurts so much.” Which of the following interventions is the nurse’s priority action?

a.            Encourage the client to relax and take deep breaths during the dressing change.

Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client’s anxiety about the procedure. However, there is another intervention that is the priority.

b.            Educate the client about the importance of the dressing change to prevent infection.

Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority.

c.             Assist the client to a comfortable position for the dressing change.

Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority.

d.            Administer pain medication 45 min before changing the client’s dressing.

The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the client’s physiological need for comfort and pain relief. Therefore the priority intervention is to administer an analgesic 30 to 60 min before changing the client’s dressing.

 

17.          A nurse is assessing a client’s readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

a.            “I can concentrate best in the morning.”

The client’s statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

b.            “It is difficult to read the instruction because my glasses are at home.”

The client’s statement indicates the client is not ready to learn. The client has to have the tools he needs to learn and comprehend the information.

c.             “I’m wondering why I need to learn this.”

The client’s statement indicates a reluctance to learn information he thinks he might not need to know.

d.            “You will have to talk to my wife about this.”

With this statement the client is redirecting the nurse’s attempt to teach toward someone else, indicating that he is not ready to learn.

 

18.          A nurse is evaluating a client’s use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

a.            The top of the cane is parallel to the client’s waist.

The top of the cane should be parallel to the client’s greater trochanter

b.            When walking, the client moves the cane 46cm (18 in) forward.

To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time.

c.             The client holds the cane on the stronger side of her body.

The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

d.            The client moves her stronger limb forward with the cane.

The client should move her weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.

 

19.          A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

a.            “Use the complete name of the medication magnesium sulfate.”

The institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

b.            “Delete the space between the numerical dose and the unit of measure.”

The Institute for Safe Medications Practices recommends including a space between the dose and the unknit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages.

c.             “Writhe letter U when noting the dosage of insulin.”

The Institute for Safe Medication Practices designates “unit(s)” as the correct term for use in medication documentations.

d.            “Use the abbreviation SC when indicating an injection.”

The Institute for Safe Medication Practices designates either “subcut” or “subcutaneously” as the correct for use in medication documentation.

 

20.          A nurse is caring for a client who is postoperative following a knee arthroplasty and requires for use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

a.            Assist the client into a prone position.

The nurse should place the client in a dorsal recumbent or semi-Fowler’s position to facilitate application of the sleeves.

b.            Place a sleeve over the top of each leg with the opening at the knee.

The nurse should place the sleeve under each leg with the opening at the knee and then the sleeve around the leg so that it is secure.

c.             Make sure two finger can fit under the sleeves.

The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

d.            Set the ankle pressure at 65 mmHg. 

The nurse should set the ankle pressure between 35 and 55 mmHg to achieve a therapeutic effect while also preventing damage to the client’s skin and circulatory impairment.

 

21.          A nurse in a long-term care facility is caring for a client who dies during the nurse’s shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

a.            Place a name tag on the body.

b.            Obtain the pronouncement of death from the provider.

c.             Remove tubes and indwelling lines.

d.            Wash the client’s body.

e.            Ask the client’s family members if they would like to view the body.

 

Answer: B, C, D, E, A.

 

22.          A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

a.            Check the client for injuries.

The first action the nurse should take when using the nursing process is to assess the client for injuries.

b.            Move hazardous objects away from the client.

Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first.

c.             Notify the provider.

The nurse should notify the provider of the client’s fall; however, there is another action the nurse should take first.

d.            Ask the client to describe how she felt prior to the fall.

Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take first.

 

23.          A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client’s room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

a.            “I will return shortly after I document this in your record.”

Although it is helpful to assure the client that the nurse will return, reminding him about the nurse’s need to perform certain tasks is likely to sound dismissive of his profound needs at this time. 

b.            “Most men live a long time with prostate cancer.”

This statement provides false reassurance. The nurse cannot predicts what the client’s outcome might be.

c.             “I am available to talk if you should change your mind.”

When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available foe the client.

d.            “I will make a referral to a cancer support group for you.” 

Dismissing the client’s concerns by referring him elsewhere without specific intervention by the nurse it is a nontherapeutic response.

 

24.          A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

a.            “We would consult the person appointed by your health care proxy to make decisions.”

The staff must honor the client’s wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client’s health care proxy to make decisions about the client’s care.

b.            “We would give toy oxygen through a tube in your nose.”

Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

c.             “You would be unable to change your previous wishes about your care.”

Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives.

d.            “We would insert a breathing tube while we evaluate your condition.”

Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.  

 

25.          A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

a.            Have the client wear a mask when receiving visitors.

The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions.

b.            Limit the client’s time with visitors to no more than 30 min per day.

Limiting the client’s time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation.

c.             Assign the client to a room with negative pressure airflow exchange.

The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne. 

d.            Wear a gown when caring for the client.

The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.

 

26.          A client who is postoperative is verbalizing pain as a 2 on a pain scale 0 to 10. Which of the following statement should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

a.            “I think I should take my pain medication more often, since it is not controlling my pain.”

As a 2 on a scale of 0 to 10, this client’s pain is mild. Additional analgesic medication is unnecessary at this time.

b.            “Breathing faster will help me keep my mind off of the pain.”

Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain.

c.             “It might help me to listen to music while I’m lying in bed.”

Listening to music is an effective nonpharmacological intervention for the management of mild pain.

d.            “I don’t want to walk today because I have some pain.”

Postoperative clients need to ambulate even if they are having mild pain.

 

27.          A nurse is administering an otic medication to an older adult client. Which of the following actions should take to ensure that the medication reaches the inner ear?

a.            Press gently on the tragus of the client’s ear.

Pressing gently on the tragus of the ear will help the medication get into the inner ear. 

b.            Pack a small piece of cotton deep into the client’s ear canal.

Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward.

c.             Move the client’s auricle down and back toward her head.

For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal.

d.            Tilt the client’s head backward for 5 min.

The client should lie on one side with the ear that received the instillation facing upward for 2 to 5 min.

 

28.          A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

a.            The client uses a wood blanket on their bed.

The client should use a cotton blanket instead of a wool blanket to avoid generating static electricity that could ignite the oxygen.

b.            The client uses nonacetone nail polish remover.

The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen. 

c.             The client stores an extra oxygen tank on its side under their bed.

The client should store extra oxygen tanks in an upright position to maintain safety.

d.            The client has a weekly inspection checklist for oxygen equipment.

The client or caregiver should inspect oxygen equipment daily.

 

29.          A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

a.            Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.

The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter.

b.            Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

Evidence-based research supports that a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

c.             Make sure the reservoir bag of partial rebreathing mask remains deflated.

The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale.

d.            Use petroleum jelly to lubricate the client’s nares, face, and lips.

Evidence-based research supports the use of water soluble lubricant to protect the client’s skin from the drying effects of oxygen.

 

30.          A nurse is reviewing a client’s fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

a.            BUN 15 mg/dL

This value is within the expected reference range of 10- 20 mg/dL.

b.            Creatinine 0.8 mg/dL

This value is within the expected reference range of 0.5- 1.1 mg/dL for women 41- 60 years of age and 0.6- 1.3 mg/dL for men 41- 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine.

c.             Sodium 143 mEq/L

This value is within the expected reference range of 136- 145 mEq/L.

d.            Potassium 5.4 mEq/L

This value is above the expected reference range of 3.5- 5.0 mEq/L so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.