ATI Fundamentals Exam 2 Study Guide |Questions |Answers
|Rationales UPDATED ACTUAL Questions and CORRECT
Answers
1. A nurse is preparing to administer an injection to a client. Which of the
following actions should the nurse take to prevent a needlestick injury?
A. Recap the needle using two hands after use.
B. Place the uncapped needle in a bedside trash can.
C. Carry the used syringe to the medication room for disposal.
D. Use a needleless system or safety-engineered device.
Answer: D
Rationale: Using needleless systems or safety devices is the primary method to prevent
needlestick injuries. Needles should never be recapped using two hands, and they must be
disposed of in a puncture-resistant sharps container immediately.
2. A nurse is caring for a client who has Clostridium difficile (C. diff). Which of
the following infection control precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective environment
Answer: A
Rationale: C. difficile requires contact precautions, which include wearing gloves and a
gown. Hand hygiene must be performed with soap and water because alcohol-based
sanitizers are ineffective against C. diff spores.
,3. A nurse is assessing a client’s radial pulse and notes that the rhythm is
irregular. Which of the following actions should the nurse take?
A. Assess the apical pulse for a full minute.
B. Assess the pulse for 30 seconds and multiply by 2.
C. Assess the radial pulse for 15 seconds and multiply by 4.
D. Document the finding and reassess in 4 hours.
Answer: A
Rationale: When an irregular radial pulse is detected, the nurse should assess the apical
pulse for one full minute to ensure accuracy and identify the specific rhythm.
4. A nurse is teaching a client about high-fiber foods. Which of the following
foods should the nurse recommend?
A. White bread
B. Canned peaches
C. White rice
D. Black beans
Answer: D
Rationale: Legumes like black beans are excellent sources of dietary fiber. White bread,
white rice, and canned fruits (often peeled) are lower in fiber.
5. A nurse is preparing to perform hand hygiene. Which of the following is the
most important factor in removing microorganisms?
A. The temperature of the water
B. The amount of soap used
C. The type of towel used for drying
D. The duration of friction
Answer: D
Rationale: Friction is the most effective component of handwashing for physically
removing microorganisms from the skin surface.
, 6. A nurse is caring for a client who is at risk for falls. Which of the following
interventions should the nurse include in the plan of care?
A. Keep all four side rails up at all times.
B. Place the bed in the highest position.
C. Ensure the client’s bedside table is within reach.
D. Instruct the client to use socks when walking.
Answer: C
Rationale: Keeping frequently used items within reach prevents the client from
overreaching and losing balance. Socks should be non-skid; four side rails are considered a
restraint; and the bed should be in the lowest position.
7. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. Client’s skin is warm and dry to the touch.
B. Client reports pain level of 6 on a scale of 0 to 10.
C. Client states, ‘I feel nauseated.’
D. Client appears anxious about the procedure.
Answer: A
Rationale: Objective data is observable and measurable. Observations of skin temperature
and moisture are objective. Statements about nausea or pain are subjective data.
8. A nurse is caring for a client who is immobile. Which of the following
complications should the nurse monitor for?
A. Deep vein thrombosis (DVT)
B. Increased cardiac output
C. Improved joint flexibility
D. Increased muscle mass
Answer: A
|Rationales UPDATED ACTUAL Questions and CORRECT
Answers
1. A nurse is preparing to administer an injection to a client. Which of the
following actions should the nurse take to prevent a needlestick injury?
A. Recap the needle using two hands after use.
B. Place the uncapped needle in a bedside trash can.
C. Carry the used syringe to the medication room for disposal.
D. Use a needleless system or safety-engineered device.
Answer: D
Rationale: Using needleless systems or safety devices is the primary method to prevent
needlestick injuries. Needles should never be recapped using two hands, and they must be
disposed of in a puncture-resistant sharps container immediately.
2. A nurse is caring for a client who has Clostridium difficile (C. diff). Which of
the following infection control precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Protective environment
Answer: A
Rationale: C. difficile requires contact precautions, which include wearing gloves and a
gown. Hand hygiene must be performed with soap and water because alcohol-based
sanitizers are ineffective against C. diff spores.
,3. A nurse is assessing a client’s radial pulse and notes that the rhythm is
irregular. Which of the following actions should the nurse take?
A. Assess the apical pulse for a full minute.
B. Assess the pulse for 30 seconds and multiply by 2.
C. Assess the radial pulse for 15 seconds and multiply by 4.
D. Document the finding and reassess in 4 hours.
Answer: A
Rationale: When an irregular radial pulse is detected, the nurse should assess the apical
pulse for one full minute to ensure accuracy and identify the specific rhythm.
4. A nurse is teaching a client about high-fiber foods. Which of the following
foods should the nurse recommend?
A. White bread
B. Canned peaches
C. White rice
D. Black beans
Answer: D
Rationale: Legumes like black beans are excellent sources of dietary fiber. White bread,
white rice, and canned fruits (often peeled) are lower in fiber.
5. A nurse is preparing to perform hand hygiene. Which of the following is the
most important factor in removing microorganisms?
A. The temperature of the water
B. The amount of soap used
C. The type of towel used for drying
D. The duration of friction
Answer: D
Rationale: Friction is the most effective component of handwashing for physically
removing microorganisms from the skin surface.
, 6. A nurse is caring for a client who is at risk for falls. Which of the following
interventions should the nurse include in the plan of care?
A. Keep all four side rails up at all times.
B. Place the bed in the highest position.
C. Ensure the client’s bedside table is within reach.
D. Instruct the client to use socks when walking.
Answer: C
Rationale: Keeping frequently used items within reach prevents the client from
overreaching and losing balance. Socks should be non-skid; four side rails are considered a
restraint; and the bed should be in the lowest position.
7. A nurse is documenting in a client’s medical record. Which of the following
entries is an example of objective data?
A. Client’s skin is warm and dry to the touch.
B. Client reports pain level of 6 on a scale of 0 to 10.
C. Client states, ‘I feel nauseated.’
D. Client appears anxious about the procedure.
Answer: A
Rationale: Objective data is observable and measurable. Observations of skin temperature
and moisture are objective. Statements about nausea or pain are subjective data.
8. A nurse is caring for a client who is immobile. Which of the following
complications should the nurse monitor for?
A. Deep vein thrombosis (DVT)
B. Increased cardiac output
C. Improved joint flexibility
D. Increased muscle mass
Answer: A
