ATI Fundamentals 2 exam questions and answers 2023/24

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelid open. D. Direct the irrigation from the outer canthus to the inner canthus of the eye C. Exert pressure on the bony prominences. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. Other Rationales: The nurse should hold the irrigator 2.5 cm (1 in) above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube. B. Instill 100 mL of air into the NG tube before removal. C. Pinch the NG tube while removing the tube. D. Instruct the client to breathe in and out during the removal of the NG tube. C. Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. Other Rationales: The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents. A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and the anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella B. The side hip between the iliac crest and the anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Other Rationales: To administer intramuscular medication using the dorsogluteal site, the nurse should select the upper, lateral quadrant of the buttock. However, the nurse should recognize this site can increase risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is increased risk of piercing the sciatic nerve. The nurse should select the outer, posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections of less than 1 mL, the nurse may select the deltoid muscle by placing four fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three finger widths below the acromion process, or about 5 cm (2 in). To administer intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place one hand below the greater trochanter and the other hand just above the knee to locate middle portion of the muscle for the injection site. A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on the chair while making the bed. B. Hold the linens away from the body and clothing. C. Place the linens on the floor until able to pace it in a linen bag. D. Shake the clean linens to unfold. B. Hold the linens away from the body and clothing. The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms. Other Rationales: The nurse should place the soiled linens in a linen bag immediately after removing the linen from the bed to prevent the spread of microorganisms on surfaces within the client's room and exposure to personnel. Soiled linen is contaminated with microorganisms and will further contaminate the floor and attract any microorganisms present on the floor, which places the nurse and the client at risk for infection. Opening linens by shaking them causes movement of air. Air currents can carry dust and spread microorganisms throughout the room, which places the client and the nurse at risk for infection. A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate D. Purulent exudate Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection. Other Rationales: Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. Serous exudate drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery. Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage. A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food. B. Offer the client tart or sour foods first. C. Tilt the client's head backward when swalling. D. Turn on the television. B. Offer the client tart or sour foods first. The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing. Other Rationales: The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. It is preferable to suggest "dry swallows" to clear the mouth between bites of food. The client who has impaired pharyngeal swallowing should tilt the head forward to promote swallowing. The client who has impaired pharyngeal swallowing should minimize distractions at mealtimes to concentrate on chewing thoroughly and swallowing. A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape B. Montgomery Straps The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. Other Rationales: An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first. A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac. B. Apply gentle pressure in the outer opening of the eye for 2 min. C. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. D. Instruct the client to close eyes tightly after administration. A. Drop the eye medication into the lower conjunctival sac. The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. Other Rationales: The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye. The nurse should hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper touching the eye. The nurse should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication and to avoid expelling the medication or injuring the eye. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system. B. Apply a barrier cream. C. Cleanse and dry the area. D. Check the client's perineum. D. Check the client's perineum. Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation. A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly into the client's impaired ear. B. Exaggerate lip movements. C. Speak loudly. D. Face the client when speaking. D. Face the client when speaking. The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating. Other Rationales: The nurse should speak toward the client's best or normal ear. Moving closer to the better ear facilitates communication. The nurse should accentuate the words, especially the consonants, so the information does not sound like mumbling. The client's ability to read lips is inhibited when using exaggerated lip movements. The nurse who speaks loudly or shouts can cause distortion of the sounds because loud sounds are at a higher pitch. A nurse is planning to administer pain medication to a client who has pain following an abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level. B. Discuss the adverse effects of pain medication with the client. C. Obtain the client's vital signs. D. Check the client's allergies. A. Use the pain scale to determine the client's pain level. The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority when caring for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, to meet the client's physiological needs, the first action the nurse should take is to begin pain management by asking the client to describe her pain. A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long. B. Remove the stocking once per day. C. Bunch and pull the stocking halfway up the calf. D. Turn the stockings inside out up to the heel before applying. D. Turn the stockings inside out up to the heel before applying. The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles. Other Rationales: The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation. The nurse should remove the stockings once every shift to inspect the skin and check circulation. The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles that can decrease venous return. A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium A. Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing. Other Rationales: Vitamin D is important when used with calcium to prevent osteoporosis; however, it does not assist in the client's wound healing. The main function of vitamin D is to maintain normal calcium and phosphorus levels in the blood and it may protect against cancer. Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics. Iron is needed to rebuild RBCs for a client; however, neither is needed directly in the client's wound healing. Calcium is administered to prevent osteoporosis when used with vitamin D; however, it does not assist in the client's wound healing. A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time 1.5 sec B. Inability of the toddler to cry or speak. When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea. Other Rationales: The nurse should identify cyanosis as a finding associated with poor oxygenation, which could indicate an airway obstruction. The nurse should check the skin, nail beds, and mucous membranes to identify the presence of cyanosis. The presence of mild emesis does not indicate an airway obstruction. The nurse should monitor the client to ensure the client clears emesis from the oral cavity in order to prevent the airway from becoming obstructed. The expected finding for capillary refill time or blanch testing of the nail bed is less than 2 seconds; therefore, the nurse should not identify this finding as an indication of airway obstruction. Delayed capillary refill time can indicate circulatory impairment. A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag. B. Cleanse the collection port with soap and water. C. Place the specimen in a clean specimen cup. D. Clamp the tubing below the collection port. D. Clamp the tubing below the collection port. The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup. Other Rationales: The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination. The nurse should place the specimen in a sterile specimen cup to prevent contamination.