ATI Fundamentals Final Exam 166
passed verified and approved solutions.
ATI Fundamentals Final Exam 166
passed verified and approved solutions.
a nurse is admitting a client who will undergo a craniotomy. During the planning phase
of the nursing process, which of the following actions should the nurse take?
a) establish client outcomes
b) collect information about past health problems
c) determine whether the client has met specific goals
d) identify the client's specific health problem - ANSWER-a) establish client outcomes
The planning phase includes developing goals and outcomes that help the nurse create
the client's plan of care.
The nursing process:
step 1. assessment phase- collect information about past health problems (vitals, age,
height)
step 2. analysis phase- identify the client's specific health problem
step 3. planning phase- establish client goals and outcomes and selects interventions
that will help to achieve them. Also involves setting care priorities.
step 4. implementation- provides client care and uses interpersonal/technical skills
when implementing nursing interventions
step 5. evaluation phase- use critical thinking skills to determine whether the client has
met a specific goal. examines results, compares the data, identifies errors, and
considers pt's situation
a client who reports shortness of breath requests the nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
a) encourage the client to take deep breaths
b) observe the client's rate, depth, and character of respirations
c) prepare to administer oxygen
d) give the client a backrub to promote relaxation - ANSWER-b) observe the client's
rate, depth, and character of respirations
a nurse is collecting health history data from a client who is deaf and uses American
sign language(ASL) to communicate. The nurse will be working with an ASL interpreter.
Which of the following actions should the nurse take when working with the interpreter?
a) face away from the client to avoid distractions
b) pace speech to allow time for the interpreter to convey the words
c) make eye contact with the interpreter when explaining the procedure
,ATI Fundamentals Final Exam 166
passed verified and approved solutions.
d) stand in the background while the interpreter translates the message - ANSWER-b)
pace speech to allow time for the interpreter to convey the words
a nurse manager is providing teaching to a group of newly licensed nurses about the
ways that clients acquire healthcare-associated-infections (HAI's). Which of the
following routes of infection should the manager identify as an iatrogenic HAI?
a) infection required from improper hand hygiene
b) infection acquired by drug resistance
c) infection acquired by inappropriate waste disposal
d) infection acquired from diagnostic procedure - ANSWER-d) infection acquired from
diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
a nurse is caring for a client who has Clostridium difficile infection and is in contact
isolation. Which of the following actions should the nurse take?
a) wear gloves when changing the clients gown
b) use alcohol-based sanitizers to cleanse the hands
c) wear a mask when assisting the client with his meal tray
d) place the client on a complete bed rest - ANSWER-a) wear gloves when changing
the clients gown
-alcohol-based sanitizers are ineffective against the spores of C.difficile
-nurse should wear a mask when working within 3 ft of a patient with droplet precautions
-the nurse should not place the client on complete bed rest because this places him at
risk for the hazards of immobility, such as impaired skin integrity and retained
respiratory secretions. The nurse should instruct the patient to stay in his room but to
move, cough, and deep breathe at least every 2 hours
a nurse is reviewing the use of side rails with an A.P. Which of the following statements
by the A.P indicates that further teaching is required?
a) "I should not leave all 4 side rails up unless there is a prescription for restraints"
b) "an alert client will be the safest if I raise the 2 upper side rails at the head of the bed"
c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself"
d) "if a client is sedated, I should raise all 4 side rails to prevent a fall out of bed" -
ANSWER-c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
which diseases have airborne precautions? - ANSWER-Varicella, TB, and measles
which diseases have contact precautions? - ANSWER-C.diff, MRSA, scabies,
vancomycin resistant enterococci
,ATI Fundamentals Final Exam 166
passed verified and approved solutions.
which diseases have droplet precautions? - ANSWER-rubella, influenza, meningoccal,
pneumonia, streptococcal pharyngitis
A nurse in a provider's office is measuring a client & notes a loss in height from the
previous year. The nurse should identify this finding as a manifestation of which of the
following musculoskeletal system disorders?
a) osteoporosis
b) scoliosis
c) kyphosis
d) lordosis - ANSWER-a) osteoporosis
A loss of height is often an early indication of osteoporosis with occurs due to a loss of
calcium in the vertebrae which can cause them to fracture and collapse.
- scoliosis does not precipitate a decrease in the height of the client. It is an abnormal
lateral curve of the sign
- kyphosis does not precipitate a decrease in the height of a client. It is an exaggerated
posterior curvature of the thoracic spine hunchback
- lordosis does not precipitate a decrease in the height of a client. It is an exaggerated
lumbar curvature way back
Not on ATI:
The nurse is planning care for a pt with severe burns. Which of the following is this pt at
risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit - ANSWER-1. intracellular fluid deficit
Because this pt was severely burned, the fluid within the cells is diminished, leading to
an intracellular fluid deficit.
Not on ATI:
The nurse is to obtain a stool specimen from a client who reported that he is taking iron
supplements. The nurse would expect the stool to be which color?
a) Black
b) Red
c) Dark brown
d) Green - ANSWER-Black
, ATI Fundamentals Final Exam 166
passed verified and approved solutions.
A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all that
apply.
1) Pain history, including location, intensity, and quality of pain
2) Client's purposeful body movement in arranging the papers on the bedside table
3) Pain pattern, including precipitating and alleviating factors
4) Vital signs such as increased blood pressure and heart rate
5) The client's family statement about increases in pain with ambulation - ANSWER-1)
Pain history, including location, intensity, and quality of pain
3) Pain pattern, including precipitating and alleviating factors
A nurse is obtaining a clients blood pressure in a client's lower extremity. Which of the
following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh - ANSWER-d)
place the bladder of the cuff over the posterior aspect of the thigh
This is the correct position for the bladder of the class when the nurse is measuring a
lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal artery
- the nurse should measure the blood pressure with the client prone is possible
otherwise the client should lie supine with knee flexed
- the nurse should position the cuff 2.5cm (1 in) above the popliteal artery
NOT ATI
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - ANSWER-D) Re-
oxygenate the client before attempting to suction again.
a nurse is performing an admission assessment for a client who has asthma and
several food allergies. Which of the following actions should the nurse take first?
a) document the clients food allergies
b) ask the client to identify the specific food allergies
passed verified and approved solutions.
ATI Fundamentals Final Exam 166
passed verified and approved solutions.
a nurse is admitting a client who will undergo a craniotomy. During the planning phase
of the nursing process, which of the following actions should the nurse take?
a) establish client outcomes
b) collect information about past health problems
c) determine whether the client has met specific goals
d) identify the client's specific health problem - ANSWER-a) establish client outcomes
The planning phase includes developing goals and outcomes that help the nurse create
the client's plan of care.
The nursing process:
step 1. assessment phase- collect information about past health problems (vitals, age,
height)
step 2. analysis phase- identify the client's specific health problem
step 3. planning phase- establish client goals and outcomes and selects interventions
that will help to achieve them. Also involves setting care priorities.
step 4. implementation- provides client care and uses interpersonal/technical skills
when implementing nursing interventions
step 5. evaluation phase- use critical thinking skills to determine whether the client has
met a specific goal. examines results, compares the data, identifies errors, and
considers pt's situation
a client who reports shortness of breath requests the nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
a) encourage the client to take deep breaths
b) observe the client's rate, depth, and character of respirations
c) prepare to administer oxygen
d) give the client a backrub to promote relaxation - ANSWER-b) observe the client's
rate, depth, and character of respirations
a nurse is collecting health history data from a client who is deaf and uses American
sign language(ASL) to communicate. The nurse will be working with an ASL interpreter.
Which of the following actions should the nurse take when working with the interpreter?
a) face away from the client to avoid distractions
b) pace speech to allow time for the interpreter to convey the words
c) make eye contact with the interpreter when explaining the procedure
,ATI Fundamentals Final Exam 166
passed verified and approved solutions.
d) stand in the background while the interpreter translates the message - ANSWER-b)
pace speech to allow time for the interpreter to convey the words
a nurse manager is providing teaching to a group of newly licensed nurses about the
ways that clients acquire healthcare-associated-infections (HAI's). Which of the
following routes of infection should the manager identify as an iatrogenic HAI?
a) infection required from improper hand hygiene
b) infection acquired by drug resistance
c) infection acquired by inappropriate waste disposal
d) infection acquired from diagnostic procedure - ANSWER-d) infection acquired from
diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
a nurse is caring for a client who has Clostridium difficile infection and is in contact
isolation. Which of the following actions should the nurse take?
a) wear gloves when changing the clients gown
b) use alcohol-based sanitizers to cleanse the hands
c) wear a mask when assisting the client with his meal tray
d) place the client on a complete bed rest - ANSWER-a) wear gloves when changing
the clients gown
-alcohol-based sanitizers are ineffective against the spores of C.difficile
-nurse should wear a mask when working within 3 ft of a patient with droplet precautions
-the nurse should not place the client on complete bed rest because this places him at
risk for the hazards of immobility, such as impaired skin integrity and retained
respiratory secretions. The nurse should instruct the patient to stay in his room but to
move, cough, and deep breathe at least every 2 hours
a nurse is reviewing the use of side rails with an A.P. Which of the following statements
by the A.P indicates that further teaching is required?
a) "I should not leave all 4 side rails up unless there is a prescription for restraints"
b) "an alert client will be the safest if I raise the 2 upper side rails at the head of the bed"
c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself"
d) "if a client is sedated, I should raise all 4 side rails to prevent a fall out of bed" -
ANSWER-c) "if the client seems confused, I'll raise all 4 side rails so that he doesn't hurt
himself"
which diseases have airborne precautions? - ANSWER-Varicella, TB, and measles
which diseases have contact precautions? - ANSWER-C.diff, MRSA, scabies,
vancomycin resistant enterococci
,ATI Fundamentals Final Exam 166
passed verified and approved solutions.
which diseases have droplet precautions? - ANSWER-rubella, influenza, meningoccal,
pneumonia, streptococcal pharyngitis
A nurse in a provider's office is measuring a client & notes a loss in height from the
previous year. The nurse should identify this finding as a manifestation of which of the
following musculoskeletal system disorders?
a) osteoporosis
b) scoliosis
c) kyphosis
d) lordosis - ANSWER-a) osteoporosis
A loss of height is often an early indication of osteoporosis with occurs due to a loss of
calcium in the vertebrae which can cause them to fracture and collapse.
- scoliosis does not precipitate a decrease in the height of the client. It is an abnormal
lateral curve of the sign
- kyphosis does not precipitate a decrease in the height of a client. It is an exaggerated
posterior curvature of the thoracic spine hunchback
- lordosis does not precipitate a decrease in the height of a client. It is an exaggerated
lumbar curvature way back
Not on ATI:
The nurse is planning care for a pt with severe burns. Which of the following is this pt at
risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit - ANSWER-1. intracellular fluid deficit
Because this pt was severely burned, the fluid within the cells is diminished, leading to
an intracellular fluid deficit.
Not on ATI:
The nurse is to obtain a stool specimen from a client who reported that he is taking iron
supplements. The nurse would expect the stool to be which color?
a) Black
b) Red
c) Dark brown
d) Green - ANSWER-Black
, ATI Fundamentals Final Exam 166
passed verified and approved solutions.
A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all that
apply.
1) Pain history, including location, intensity, and quality of pain
2) Client's purposeful body movement in arranging the papers on the bedside table
3) Pain pattern, including precipitating and alleviating factors
4) Vital signs such as increased blood pressure and heart rate
5) The client's family statement about increases in pain with ambulation - ANSWER-1)
Pain history, including location, intensity, and quality of pain
3) Pain pattern, including precipitating and alleviating factors
A nurse is obtaining a clients blood pressure in a client's lower extremity. Which of the
following actions should the nurse take?
a) auscultate the BP at the dorsalis pedis artery
b) measure the clients BP with the client sitting at the side of the bed
c) place the cuff 7.6cm (3in) above the popliteal artery
d) place the bladder of the cuff over the posterior aspect of the thigh - ANSWER-d)
place the bladder of the cuff over the posterior aspect of the thigh
This is the correct position for the bladder of the class when the nurse is measuring a
lower extremity blood pressure
- a nurse should auscultate the blood pressure at the popliteal artery
- the nurse should measure the blood pressure with the client prone is possible
otherwise the client should lie supine with knee flexed
- the nurse should position the cuff 2.5cm (1 in) above the popliteal artery
NOT ATI
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - ANSWER-D) Re-
oxygenate the client before attempting to suction again.
a nurse is performing an admission assessment for a client who has asthma and
several food allergies. Which of the following actions should the nurse take first?
a) document the clients food allergies
b) ask the client to identify the specific food allergies
