ATI Fundamental Retake #2 Level 2, Corrected QUESTIONS AND ANSWERS LATEST VERSION

ATI Fundamental Retake #2 Level 2, Corrected QUESTIONS AND ANSWERS LATEST VERSION 1) A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? A) Cotton tip applicator to clean the inside of the cannula B) Soak the outer cannula in warm soapy tap water C) Cleanse the skin around the stoma with normal saline D) Secure the tracheostomy ties to allow one finger to fit snuggly underneath 2) A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? A) Ensure the client is free of metal objects B) Administer 240 ml (8oz) oral contrast before the procedure C) Monitor the client for pain in the suprapubic region D) Assist the client with a bowel cleansing 3) A nurse is testing a client for conduction deafness by performing the Weber’s tests. which of the following actions should the nurse take when performing the test? A) Move a vibrating tuning fork in front of the clients canals one after the other B) Place the base of the vibrating tuning fork on the top of the client’s head C) Place the base of a vibrating tuning fork on the client’s mastoid process D) Count how many seconds a client can hear a tuning fork after it has been struck 4) A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care? A) Prepare the client for a central venous line B) Change the PN infusion bag every 48 hours C) Administer the PN and fat emulsion separately D) Obtain a random blood glucose daily *5) A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching? A) Each element has a range 1 to 5 points B) The higher the score the higher the pressure ulcer risk C) The client’s age is part of the measurement D) The scale measures six elements *6) A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse’s priority? A) Determine the client’s reading ability B) Review the use of an artificial larynx C) With the client schedule a support session D) For the client explain the techniques of esophageal speech 7) A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? A) Eat a light carbohydrate snack before bedtime B) Exercise 1 hour before bedtime C) Drink a cup of hot cocoa before bedtime D) Take a 30 min nap daily 8) A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first? A) Offer pain medication B) Palpate the abdomen C) Auscultate bowel sounds D) Administer an antiemetic 9) A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn? A) The client’s belief that his needs will be met through education B) The nurse explaining the need for education to the client C) The client seeking family approval by agreeing to a teaching plan D) The nurse’s empathy about the client having to self-inject 10) A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first? A) Elimination needs B) Comfort level C) Peripheral pulses D) Skin integrity 11) A charge nurse is monitoring the documentation of the medication by a newly licensed nurse. The charge nurse should intervene if the newly licensed nurse uses which of the following abbreviations? A) OJ for orange juice B) SQ for subcutaneous C) SS for sliding scale D) BRP for bathroom privileges 12) A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement? A) Contact B) Droplet C) Airborne D) Protection 13) A nurse is caring for a client receiving continuous enteral feedings through an NG tube. Which of the following is an unexpected finding? A) Diarrhea one time in a 24-hour period B) A weight gain of 0.9 (2lb) in 2 days C) A gastric residual of 300 mL at the end of the shift D) A blood glucose level of 110 14) A nurse is preparing a sterile field to assist with nurturing a client’s laceration. Which of the following actions should the nurse plan to take? A) Pour the sterile solution with the bottle held 20 cm (8 in) above the sterile bowl B) Hold the bottle of sterile solution so that the label is facing the palm of the hand C) Place the lid of the sterile solution bottle face down on the sterile drape D) Apply sterile gloves before opening the bottle of sterile solution 15) A nurse is preparing to administer several medications to a client via NG tube to a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take first? A) Dilute each crushed medication with sterile water B) Mix the medications together in a single syringe C) Combine the medications with the formula D) Flush the NG tube with 5 mL of sterile water prior to administration 16) A nurse is reviewing the medication record of a client who asks about the use of magnet therapy for pain relief. The nurse should identify that which of the following findings is a contraindication for receiving this type of therapy? A) The client who has an implanted defibrillator B) The client who has a prescription for metoprolol C) The client is allergic to penicillin D) The client has a history of alcohol use disorder 17) A nurse is assessing the skin of a client who has worked outdoors for the past 30 years. Which of the following findings is a priority? A) A flat, nonpalpable, discolored area of skin B) A change in the appearance of a mole on the shoulder C) Skin tags in the neck region D) Atrophic wart on the left index finger 18) a nurse is preparing to insert an iv catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating an IV therapy? A) The radial vein on the left wrist B) The cephalic vein in the left distal forearm C) The basilic vein in the right antecubital fossa D) The cephalic vein on the back of the right hand 19) a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? A) Tie the restraints to the side rale B) Secure restraints with a square knot C) Remove one restraint at a time D) Remove the restraints every 3 hours 20) Dosage Calculation- Gentamicin 2mg/kg/220 lb.= 200 21) A nurse is assessing a client who has diabetes prior to performing a blood glucose test. Which of the following findings should indicate to the nurse the client has hyperglycemia? A) Thirst B) Confusion C) Cool Skin D) Shakiness 22) A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? A) Determine areas of resonance across the abdomen using a systematic approach B) Expose the client’s abdomen to look for changes in appearance C) Perform abdominal palpation by pressing gently with the finger pads D) Use the diaphragm of the stethoscope to listen for bowel sounds 23) a nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take? A) Heat the formula to 105 degrees Fahrenheit B) Flush the tubing with 10 ml of water every 2 hours C) Change the tubing every 72 hours D) Aspirate residual volume every 4 hours 24) A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? A) I can apply lotion to soften the calluses as long as I don’t put lotion between my toes B) I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly C) I should soak my feet in warm water daily to soften corns and calluses D) I should use an over-the-counter liquid medication to remove corns 25) A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? A) Plain yogurt B) Oatmeal C) Applesauce D) Scrambled eggs 26) A community health nurse is teaching a group of clients about Kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse Include? A) Contact your pelvic muscle when performing the exercises B) Tighten your button when performing the exercise C) Hold your breath while performing the exercise D) Expect improvement after 2 weeks for performing this exercise 27) A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? A) You will receive written information about advance directives prior to signing B) Your partner must be present when you sign the advanced directive C) You are required to sign the advanced directive before surgery D) Your provider must sign the advanced directive 28) A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take? A) Schedule postural drainage after meals B) perform percussion over the lower back C) instruct the client to exhale quickly during vibration D) cover the area of precaution with a towel 29) A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? A) Inject air into the short acting insulin vial. B) Draw up the intermediate insulin into the syringe C) Draw the short-acting insulin into the syringe D) Inject air into the intermediate-acting insulin vial 30) A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? SATA A) Oral suction equipment B) Oral airway C) Supplemental oxygen D) Blood glucose monitor E) Limb restraints 31) A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A) Dilated pupils B) Bradycardia C) Depression D) Physical exhaustion 32) A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A) Client premedicated with MSO4 subq prior to dressing change B) The wound seems clean and does not appear to be infected C) New dressing applied as prescribed, no drainage on old dressing D) No changes noted to the wound from previous nursing notes 33) A nurse is caring for a client who had a stroke and requires assistance with morning ADL’s. Which of the following interprofessional team members should the nurse consult? A) Speech language pathologist B) Registered dietician C) Physical therapist D) Occupational therapist 34) A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? A) I should limit the time that I spend sitting in a chair B) I will perform leg exercises once every four hours C) I should massage my legs when they hurt D) I will keep my legs crossed while sitting 35) A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? A) Keep the drainage bag below the level of the bladder B) Tape the catheter to the lower abdomen C) Attach the drainage bad to the side rails of the bed D) Empty the drainage bag when it is ¾ filled 36) A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A) Obtain the client’s vital signs B) Report the incident to the unit manager C) Complete an incident report D) Document the fluid infusion in the client’s chart 37) A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? A) Apply a bath blanket between the client and a cooling blanket B) Give the client a sponge bath using alcohol water solution C) Place ice packs on the client’s neck and behind the knees D) Cover the client with heavy blankets after shivering subsides 38) A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A) The client states that he is able to concentrate while eating B) The clients’ vital signs are within the normal range C) The client is laughing at a television show D) The client’s skin on the lower back is intact without redness 39) A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take? A) Place the extremity in a dependent position B) Apply a cool compress for several minutes before insertion C) Place the tourniquet below the proposed insertion site D) Choose the most proximal site on the extremity selected 40) A nurse is delegating client care to assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP. A) Changing IV tubing B) Inserting NG tube C) Evaluating the healing of an incision D) Performing a simple dressing change 41) A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identity? A) Photograph B) Room number C) Bed number D) Age 42) A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? A) I should gradually increase the time that I wear the hearing aid B) I need to get a new hearing aid every year C) I should leave the battery in the hearing aid when I sleep D) After I insert the hearing aid, I should turn it all the way up 43) A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use? A) The shallow end of the fracture pan under the client’s buttocks B) Hyperextend the clients back while the fracture pan is still in place C) Encourage the client to defecate for 20 minutes D) Keep the bed flat while the client is on the bed pan 44) A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? A) Schedule the client as the first surgical procedure of the day B) Cleanse the stoppers with primidone iodine for withdrawing medication C) Remove the stop stocks from iv tubing D)Ensure the gloves in the surgical suite are powdered gloves 45) A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A) Use medical terminology when giving information to the client B) Address all questions to the interpreter C) Have the client nod to indicate understanding D) Recommend an interpreter the same gender as the client 46) A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? A) Provide the client with a contact number for a diabetes education specialist B) Make a copy of the medication record of the reconciliation for the client C) Determine whether the client can afford the insulin administration supplies D) Obtain printed information about self-administration 47) A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? A) Develop a list of goals with the client B) Help the client to find a local support group C) Discuss the clients prior coping mechanisms D) Teach the client to use progressive relaxation techniques