ATI Fundamentals Test Exam 20 2024
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.
B. When walking, the client moves the cane 46cm forward
C. the client holds the cane on the stronger side of her body.
D. the client moves her stronger limb forward with the cane. - C. the client should hold the
cane on the stronger side of her body to increase support and maintain alignment. The top of
the cane should be parallel to the greater trochanter, the client should only advance the cane
14-30cm at a time, the client should move the weak leg with the cane for support.
A nurse receives report about a client who has NS infusing IV at 125ml/hr. When the nurse
performs the initial assessment, he notes that the client has received only 80ml over the last 2
hr. Which of the following actions should the nurse take first?
A. reposition the client
B. Document the client's IV intake in the medical record.
C. Request a new IV fluid prescription.
D. Check the IV tubing for obstruction. - D. Check the IV tubing for obstruction.
The nurse should reposition but this isn't the first step, the nurse should document but this too
isn't the first step. The nurse should request new IV fluid prescription to compensate for lost
fluid but this isn't the first step.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of
the following actions should the nurse take when inserting the NG tube?
A. position the client with the head of the bed elecated to 30 degrees prior to insertion of the
NG tube
B. Remove the NG tube if the client begins to gag or choke.
C. Apply suction to the NG tube prior to insertion
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus -
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
The client should be in high-fowlers position, the nurse shoud withdraw the NG tube slightly
not remove it if the client gags, the nurse should not apply suction unless NG tube is verified
by x-ray.
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
B. Creatinine 0.8 mg/dl
C. Sodium 143 mEq/L
D. Potassium 5.4 mEq/L - D. Potassium 5.4 mEq/L. Potassium should be 3.5-5.
Bun is 10-20, Creatinine is 0.5 - 1.1, Sodium is 136-145
A nurse is providing discharge instructions to a client who will be using a walker. Which of
the following client statements indicates an understanding of the teaching?
A. "I can place an extension cord across my living room to plug in my television."
B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
C. " I will place my alarm clock on my bedroom dresser across the room."
, D. "I will replace the old throw rug in my kitchen with a new one." - B. "I will hire someone
to trim the tree that hangs low over the stairs of my front porch."
Extension cords should be fastened to the floor, frequently used items like an alarm clock,
glasses, or disposable tissues should be within reach, throw rugs increase risk and should be
removed.
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? select all that
apply
A. Assist the client with a partial bed bath.
B. Measure the client's BP after the nurse administers an antihypertensive medication.
C. Test the client's swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch
E. Irrigate the client's indwelling urinary catheter - A, B, D
These are within the AP's range of function all others require a nurse.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer.
Which of the following actions should the nurse take?
A. Discuss the risk factors for colon cancer.
B. focus teaching on what the client will need to do in the future to manage his illness.
C. provide the client with written information about the phases of loss and grief
D. Reassure the client that this is an expected response to grief. - D. Reassure the client that
this is an expected response to grief.
The client might perceive the discussion of risk factors as challenging or argumentative, the
nurse should focus the teaching on the present psychosocial adaptation and not the future
management, unless the client requests material this is not a good time, this is when the client
needs to express their feelings.
The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressing should the nurse use?
A. Alginate
B. Gauze
C. Transparent
D. Hydrocolloid - D. Hydrocolloid promote healing in stage 2 by creating a moist wound bed.
Alginate dressing are for stage 3 and 4 injuries to absorb drainage,
moist guaze is for stage 4 or unstageable dressing that need debridement, transparent dressing
are for stage 1 to prevent further friction.
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear?
A. Press gently on the tragus of the client's ear.
B. Pack a small piece of cotton deep into the client's ear canal.
C. Move the client's auricle down and back toward her head.
D. Tilt the clients head backward for 5 min. - A. Press gently on the traugus of the ear will
help the medication get into the inner ear.
Pushing in cotton could damage the ear, the auricle should be moved upward and back to
straighten canal, and the client should lie on their side with ear upward for 2-5 minutes to let
gravity move the medication.
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.
B. When walking, the client moves the cane 46cm forward
C. the client holds the cane on the stronger side of her body.
D. the client moves her stronger limb forward with the cane. - C. the client should hold the
cane on the stronger side of her body to increase support and maintain alignment. The top of
the cane should be parallel to the greater trochanter, the client should only advance the cane
14-30cm at a time, the client should move the weak leg with the cane for support.
A nurse receives report about a client who has NS infusing IV at 125ml/hr. When the nurse
performs the initial assessment, he notes that the client has received only 80ml over the last 2
hr. Which of the following actions should the nurse take first?
A. reposition the client
B. Document the client's IV intake in the medical record.
C. Request a new IV fluid prescription.
D. Check the IV tubing for obstruction. - D. Check the IV tubing for obstruction.
The nurse should reposition but this isn't the first step, the nurse should document but this too
isn't the first step. The nurse should request new IV fluid prescription to compensate for lost
fluid but this isn't the first step.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of
the following actions should the nurse take when inserting the NG tube?
A. position the client with the head of the bed elecated to 30 degrees prior to insertion of the
NG tube
B. Remove the NG tube if the client begins to gag or choke.
C. Apply suction to the NG tube prior to insertion
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus -
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
The client should be in high-fowlers position, the nurse shoud withdraw the NG tube slightly
not remove it if the client gags, the nurse should not apply suction unless NG tube is verified
by x-ray.
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
B. Creatinine 0.8 mg/dl
C. Sodium 143 mEq/L
D. Potassium 5.4 mEq/L - D. Potassium 5.4 mEq/L. Potassium should be 3.5-5.
Bun is 10-20, Creatinine is 0.5 - 1.1, Sodium is 136-145
A nurse is providing discharge instructions to a client who will be using a walker. Which of
the following client statements indicates an understanding of the teaching?
A. "I can place an extension cord across my living room to plug in my television."
B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
C. " I will place my alarm clock on my bedroom dresser across the room."
, D. "I will replace the old throw rug in my kitchen with a new one." - B. "I will hire someone
to trim the tree that hangs low over the stairs of my front porch."
Extension cords should be fastened to the floor, frequently used items like an alarm clock,
glasses, or disposable tissues should be within reach, throw rugs increase risk and should be
removed.
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? select all that
apply
A. Assist the client with a partial bed bath.
B. Measure the client's BP after the nurse administers an antihypertensive medication.
C. Test the client's swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch
E. Irrigate the client's indwelling urinary catheter - A, B, D
These are within the AP's range of function all others require a nurse.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer.
Which of the following actions should the nurse take?
A. Discuss the risk factors for colon cancer.
B. focus teaching on what the client will need to do in the future to manage his illness.
C. provide the client with written information about the phases of loss and grief
D. Reassure the client that this is an expected response to grief. - D. Reassure the client that
this is an expected response to grief.
The client might perceive the discussion of risk factors as challenging or argumentative, the
nurse should focus the teaching on the present psychosocial adaptation and not the future
management, unless the client requests material this is not a good time, this is when the client
needs to express their feelings.
The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressing should the nurse use?
A. Alginate
B. Gauze
C. Transparent
D. Hydrocolloid - D. Hydrocolloid promote healing in stage 2 by creating a moist wound bed.
Alginate dressing are for stage 3 and 4 injuries to absorb drainage,
moist guaze is for stage 4 or unstageable dressing that need debridement, transparent dressing
are for stage 1 to prevent further friction.
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear?
A. Press gently on the tragus of the client's ear.
B. Pack a small piece of cotton deep into the client's ear canal.
C. Move the client's auricle down and back toward her head.
D. Tilt the clients head backward for 5 min. - A. Press gently on the traugus of the ear will
help the medication get into the inner ear.
Pushing in cotton could damage the ear, the auricle should be moved upward and back to
straighten canal, and the client should lie on their side with ear upward for 2-5 minutes to let
gravity move the medication.
