Fundamentals ATI Practice Test B 100% Verified (56 Q&As) Latest Update 2023/2024

Fundamentals ATI Practice Test B 1. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. when the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. which of the following actions should the nurse take first? Check the IV tubing for obstruction. Rationale: The first action the nurse should take using the nursing process is to assess the client. By checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. 2. 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? Administer pain medication 45 min before changing the client’s dressing. Rationale: 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. 3. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? Examine the personal values about the issue. Rationale: The nurse should examine her own personal values about the issue to help her provide care that is without bias. 4. A middle adult client tells the nurse, “I feel so useless now that my children do not need me anymore.” Which of the following responses should the nurse make? “People in middle adulthood often find satisfaction in nurturing and guiding young people.” Rationale: According to Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus on this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage such as volunteering and mentoring. 5. A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? An x-ray shows the end of the tube above the pylorus. Rationale: An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement. 6. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? Second intercostal space at the left sternal border. This is the area over the pulmonary valve. The nurse should listen over this, apex and the other valve areas for the rate and rhythm, as well as gallops and murmurs. 7. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? The family member washes out the feeding bag with warm water once every 24 hr. Rationale: The family member should wash out the feeding bag at each refilling throughout the day (every 4 to 8 hr) replace it with a new feeding bag every 34 hr to prevent bacterial contamination. Therefore, the nurse should reinforce this information with the family member. 8. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (select all that apply.) Check the cord routinely for frays or tearing. Consider purchasing a generator for power backup. Observe for signs of hypoxia Rationale: • Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. • Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of the oxygen he needs. The nurse should also instruct the family to explore getting the client on their municipality’s priority list for restoring power after an outage occurs. • The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor and cyanosis. Even with supplemental oxygen, the client’s status can worsen, and he can develop hypoxia. 9. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching, she received about pain management? “It might help me to listen to music while I’m lying in bed.” Rationale: Listening to music is an effective nonpharmacological intervention for the management of mild pain. 10. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? Apply intermittent suction when withdrawing the catheter. Rationale: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. 11. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? Wash her hands before and after contact with the client. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contact with every client, regardless of their diagnosis. 12. The 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? Pad the wrist before applying the restraints. Rationale: Restraints without padding can abrade the client’s skin. 13. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? Insert the IV catheter without using a tourniquet. Rationale: The nurse should insert the IV catheter using the tourniquet minimally or not at all to avoid injury of fragile skin over veins. 14. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client’s plan of care? Wrap blankets around all four sides of the bed. Rationale: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures. 15. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? “We can talk about advance directives, and I can also give you some brochures about them.” Rationale: With the statement, the nurse offers to provide the information the client needs in a direct and simple way. 16. 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.) Assist the client with a partial bed bath. Measure the client’s BP after the nurse administers an antihypertensive medication. Use a communication board to ask what the client wants for lunch. Rationale: • Assisting the client with a bed bath poses minimal risk to the client and fits within the AP’s range of function. • Measuring the client’s BP poses minimal risk to the client and fits within the AP’s range of function. • Using a communication board poses minimal risk to the client and fits within the AP’s range of function.