ATI PROCTORED FUNDAMENTAL EXAM
QUESTIONS AND ANSWER KEY
◉ A nurse is teaching a group of older adults about expected
changes of aging. Which of the following statements by a group
member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal
after exercise as I get older."
"Urinary incontinence is something I will have to live with as I grow
older."
"I can expect to have less ear wax as I get older."
"My stomach will empty more quickly after meals as I grow older.".
Answer: "I should expect my heart rate to take longer to return to
normal after exercise as I get older."
Rationale:
Older adults experience decreased cardiac output, which causes
increased pulse rate during exercise. The pulse rate also takes longer
to return to normal after exercise.
,◉ A nurse is caring for a client who is postoperative and has
paralytic ileus. Which of the following abdominal assessments
should the nurse expect?
Frequent bowel sounds with flatus
Absent bowel sounds with distention
Hyperactive bowel sounds with diarrhea
Normal bowel sounds with increased peristalsis.
Answer: Absent bowel sounds with distention
Rationale:
Paralytic ileus is an immobile bowel. With this disorder, bowel
sounds are absent and the abdomen is distended.
◉ A nurse is planning care for a client who reports abdominal pain.
An assessment by the nurse reveals the client has a temperature of
39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen,
and menses overdue by 2 days. Which of the following findings
should be the nurse's priority?
,Heart rate 105/min
Soft, nontender abdomen
Temperature
Overdue menses.
Answer: Temperature
Rationale:
Elevated temperature is an emergent physiological need, which
requires priority intervention by the nurse. The nurse should
consider Maslow's Hierarchy of Needs, which includes five levels of
priority. 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, the
nurse should review physiological needs first. The nurse should then
address the client's needs by following the remaining four hierarchal
levels. However, it is important 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 situation.
, ◉ A nurse is caring for a child who is postoperative following a
tonsillectomy. Which of the following actions should the nurse take?
Encourage the child to cough frequently to clear congestion from
anesthesia.
Place a heating pad at the child's neck for comfort.
Administer analgesics to the child on a routine schedule throughout
the day and night.
Provide the child with ice cream when oral intake is initiated..
Answer: Administer analgesics to the child on a routine schedule
throughout the day and night.
Rationale:
To soothe the client's throat following a tonsillectomy, the nurse
should administer pain medication routinely around the clock. The
nurse can provide the medication rectally or intravenously to avoid
the oral route.
◉ A nurse is assessing the heart sounds of a client who has
developed chest pain that becomes worse with inspiration. The
nurse auscultates a high-pitched scratching sound during both
QUESTIONS AND ANSWER KEY
◉ A nurse is teaching a group of older adults about expected
changes of aging. Which of the following statements by a group
member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal
after exercise as I get older."
"Urinary incontinence is something I will have to live with as I grow
older."
"I can expect to have less ear wax as I get older."
"My stomach will empty more quickly after meals as I grow older.".
Answer: "I should expect my heart rate to take longer to return to
normal after exercise as I get older."
Rationale:
Older adults experience decreased cardiac output, which causes
increased pulse rate during exercise. The pulse rate also takes longer
to return to normal after exercise.
,◉ A nurse is caring for a client who is postoperative and has
paralytic ileus. Which of the following abdominal assessments
should the nurse expect?
Frequent bowel sounds with flatus
Absent bowel sounds with distention
Hyperactive bowel sounds with diarrhea
Normal bowel sounds with increased peristalsis.
Answer: Absent bowel sounds with distention
Rationale:
Paralytic ileus is an immobile bowel. With this disorder, bowel
sounds are absent and the abdomen is distended.
◉ A nurse is planning care for a client who reports abdominal pain.
An assessment by the nurse reveals the client has a temperature of
39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen,
and menses overdue by 2 days. Which of the following findings
should be the nurse's priority?
,Heart rate 105/min
Soft, nontender abdomen
Temperature
Overdue menses.
Answer: Temperature
Rationale:
Elevated temperature is an emergent physiological need, which
requires priority intervention by the nurse. The nurse should
consider Maslow's Hierarchy of Needs, which includes five levels of
priority. 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, the
nurse should review physiological needs first. The nurse should then
address the client's needs by following the remaining four hierarchal
levels. However, it is important 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 situation.
, ◉ A nurse is caring for a child who is postoperative following a
tonsillectomy. Which of the following actions should the nurse take?
Encourage the child to cough frequently to clear congestion from
anesthesia.
Place a heating pad at the child's neck for comfort.
Administer analgesics to the child on a routine schedule throughout
the day and night.
Provide the child with ice cream when oral intake is initiated..
Answer: Administer analgesics to the child on a routine schedule
throughout the day and night.
Rationale:
To soothe the client's throat following a tonsillectomy, the nurse
should administer pain medication routinely around the clock. The
nurse can provide the medication rectally or intravenously to avoid
the oral route.
◉ A nurse is assessing the heart sounds of a client who has
developed chest pain that becomes worse with inspiration. The
nurse auscultates a high-pitched scratching sound during both
